Cigna / Evernorth ABA coverage in Kansas: 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]

Cigna (Evernorth Behavioral Health) makes "coverage determinations in accordance with the time frames required under applicable law," and warns: "You must supply all information requested within the time frames specified … Failure to provide information within the time frames requested may result in nonpayment." ABA requests go to the Autism Utilization Management team. Lead time is published: "For ABA, we encourage 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" — so file each reauthorization up to 30 days before the current one ends. Kansas fully insured plans are held to the Insurance Department's utilization-management standards adopted by K.A.R. 40-4-41: prospective (pre-service) review "Within 15 calendar days of the receipt of request" (one 15-calendar-day extension, with at least 45 days to supply missing information) and "no later than 72 hours" for urgent care; an urgent request to extend a current course of treatment is decided within 24 hours if received "at least 24 hours before the expiration of the currently certified period." Self-funded ERISA plans land on the same numbers under 29 CFR 2560.503-1 (15 days, 72 hours urgent), so 15 calendar days / 72 hours from receipt is the ceiling either way.^[7][2][8][9]

Evernorth follows the NAIC order "subject to applicable law and the terms of the benefit plan": "The plan of the parent whose birthday falls earlier in the calendar year is primary … Only the month and day of birth are relevant" (same birthday: the longer-running plan); a court decree controls for divorced or separated parents, and with no decree the order is custodial parent, custodial parent's spouse, noncustodial parent, noncustodial parent's spouse. Kansas's COB rule (K.A.R. 40-4-34) governs fully insured plans: for a child whose parents are 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 has covered the parent longest); for divorced or separated parents a court decree naming the responsible parent controls. When Cigna is secondary, bill the primary first, then send the claim "along with a copy of the primary payer's EOP" (not needed if HIPAA-compliant COB data goes electronically to payer ID 62308). If the child also has Medicaid, this plan pays first: Medicaid is payer of last resort (42 CFR 433.139) — bill here, then send the EOB or denial to Medicaid, and get Medicaid's own prior auth too if the state requires it. TRICARE is secondary to this plan ("TRICARE shall be last pay," 32 CFR 199.8), and "CHAMPVA is the last payer to OHI" (38 CFR 17.276(d)).^{[7][10][11][12][13]}

K.S.A. 40-2,194 limits the mandate to covered individuals under age 12, on fully-insured large-group coverage only (51+ employees since 2023's SB 24), with ABA capped at 1,300 hours a year for four years for a child diagnosed between birth and age 5 and 520 hours a year otherwise — caps a plan may exceed with prior approval when medically necessary. Advocacy analysis (not a regulator determination) treats the under-12 limit and the hour caps as unenforceable quantitative treatment limits under MHPAEA for parity-covered plans, so treat an age- or cap-based denial as appealable rather than final. The carrier's national ABA policy sets no age bound of its own.^[3][1]

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

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.