---
title: "Cigna / Evernorth ABA coverage in Kansas: the intake guide."
url: "https://carelu.com/payers/cigna-kansas"
markdown_url: "https://carelu.com/payers/cigna-kansas.md"
state: KS (Kansas)
payer: Cigna / Evernorth in Kansas
kind: Commercial insurance
description: "How Cigna / Evernorth covers ABA for Kansas families — the national clinical policy, prior authorization, the K.S.A. 40-2,194 mandate (under-12 age limit, hour caps, exemptions), Kansas behavior-analyst licensure, and what intake should verify."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

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

_Payer Guide · Cigna · Kansas · Last updated September 2026 · 6 primary sources_

> EN0499 + autism resource guide + the K.S.A. 40-2,194 mandate layer; no Kansas carve-out.

For an intake team in Kansas, a Cigna card means three layers at once: the carrier's national clinical policy, Kansas's autism insurance mandate (K.S.A. 40-2,194), 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:** K.S.A. 40-2,194 — large group (51+) only
- **Mandate age:** Under age 12 only
- **Mandate caps:** 1,300 hrs/yr × 4 yrs (dx by age 5), else 520 hrs/yr — exceedable with prior approval; parity-questioned
- **Exempt from mandate:** Self-funded ERISA; small employers (2–50) via waiver; limited-benefit plans
- **Licensure:** KS Licensed Behavior Analyst (BSRB), required since 7/1/2016

## The national policy, applied in Kansas

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 Kansas is the legal floor underneath it: the state mandate below governs what fully-insured large-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 Kansas. [1][2]

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

Kansas's mandate, K.S.A. 40-2,194, is one of the narrower ones in our directory. It reaches large-group policies, service-corporation contracts, fraternal benefit societies, and HMOs (issued/renewed after 1/1/2015; grandfathered plans from 1/1/2016), and 2023's SB 24 redefined "large employer" down to 51+ employees. Coverage is limited to covered individuals under age 12, and ABA carries hour-based caps: 1,300 hours/year for 4 years for a child diagnosed between birth and age 5, otherwise 520 hours/year until age 12 — though plans may exceed the caps with prior approval when medically necessary, the statute's own escape valve. Day care, facility-based, and school-based services are excluded; after 7/1/2016 ABA under the mandate must be delivered by providers licensed or exempt under the ABA licensure act. Small employers (2–50) can obtain a waiver by showing a 2.5%+ premium increase, self-funded ERISA plans sit outside the statute entirely, and a member diagnosed under any DSM edition cannot be forced into re-evaluation upon DSM revision. Advocacy analysis (not a regulator determination) treats the under-12 age limit and hour caps as unenforceable quantitative limits under MHPAEA for parity-covered plans — so treat cap-based denials as appealable, not final. [3][4][6]

## No Kansas-specific Cigna policy exists

We checked the current EN0499 line by line: it contains no Kansas entry and no Kansas carve-out — the national criteria apply in Kansas, subject to the standard proviso that state law and the plan contract can override. Cigna also operates no Medicaid plan in Kansas, so a Cigna card here is always commercial. That makes benefits verification (plan funding type, mandate applicability, benefit limits) the place Kansas-specific answers come from, not a carrier document. [1]

## Licensure & rates in Kansas

Kansas has required licensure for practicing behavior analysts since July 1, 2016: the Licensed Behavior Analyst (LBA) and Licensed Assistant Behavior Analyst (LaBA) credentials under the applied behavior analysis licensure act (K.S.A. 65-7501 et seq.), administered by the Behavioral Sciences Regulatory Board and keyed to BACB certification — and the mandate itself conditions ABA coverage on licensed or exempt providers, so licensure is a coverage requirement, not just a credentialing one. On rates: Cigna does not publish commercial ABA fee schedules for Kansas (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement. The usual Medicaid benchmark is also unusually opaque here: current KanCare autism-services rates are only available through the KMAP interactive fee-schedule lookup, so pull them there before a rate negotiation. [5]

## Intake gates

The questions that decide whether a family can start with Cigna / Evernorth in Kansas, 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]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: 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]
- **Age limit** _(plan-dependent)_: 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.

## Delivery and billing rules

Coverage decides whether Cigna / Evernorth in Kansas 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 Kansas

- **Plan funding type:** Fully insured large group (mandate applies) vs. self-funded ERISA (exempt) vs. small group (waiver-eligible) — 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:** DSM-5 ASD diagnosis, diagnosing provider and credentials, evaluation date.
- **Age + diagnosis age:** The mandate's under-12 limit and its 1,300-vs-520 hour tiers key off age at diagnosis — flag edge cases for parity 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 Kansas 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 national medical-necessity policy only; no Kansas-specific coding/reimbursement mechanics published.

### Contacts

- **Provider services phone:** 800.926.2273 (Provider Services — billing, benefits, eligibility)
- **Phone menu path:** For autism/ABA-specific benefits, eligibility, and authorization questions, ask for the Autism Care Coordinator team instead (877.279.7603) — a nonclinical team dedicated to ABA.
- **Hours:** Provider Services: Monday–Friday, 7:00 a.m.–7:00 p.m. CT. Autism Care Coordinator team: Monday–Friday, 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 per-code unit caps, POS codes, and telehealth modifiers for 97151–97158/0362T/0373T on this member’s plan?
- Is eligibility/benefits checking real-time or batch through pVerify/Availity for payer ID 62308?

### 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 Kansas?

Yes — under the carrier's national EN0499 policy for ASD (no prior auth on assessment codes; PA at the treatment step), layered on Kansas's mandate (K.S.A. 40-2,194) for fully-insured large-group plans. Self-funded plans are exempt from the mandate, so verify funding type first.

### What does the Kansas autism mandate require?

For large-group (51+) fully-insured plans: coverage for members under 12, with ABA capped at 1,300 hours/year for 4 years when diagnosed by age 5, otherwise 520 hours/year — exceedable with prior approval when medically necessary. Federal parity analysis questions the age limit and hour caps, so treat cap denials as appealable.

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

Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. The Medicaid benchmark exists only via the KMAP interactive fee-schedule lookup.

## 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. [K.S.A. 40-2,194 (Kansas Revisor of Statutes)](https://ksrevisor.gov/statutes/chapters/ch40/040_002_0194.html)
4. [2023 Session Laws Ch. 3, SB 24](https://sos.ks.gov/publications/sessionlaws/2023/Chapter-03-SB-24.html)
5. [K.S.A. 65-7502 — ABA licensure act definitions](https://ksrevisor.gov/statutes/chapters/ch65/065_075_0002.html)
6. [Autism Legal Resource Center — Kansas (parity analysis)](https://www.autismlegalresourcecenter.com/resources/autism-healthcare-info/kansas/)
7. [Evernorth Behavioral Health Administrative Guidelines (PCOMM-2026-191, March 2026)](https://static.evernorth.com/assets/evernorth/provider/pdf/resourceLibrary/behavioral/ebh-provider-admin-guide.pdf)
8. [K.A.R. 40-4-41 — Kansas Insurance Department Policy and Procedure Relating to Health Utilization Management Standards (March 22, 2016), HUM 19/21](https://insurance.ks.gov/documents/department/regulations-adopted/article-4/40-4-41-URAC-Policy.pdf)
9. [29 CFR 2560.503-1(f)(2) — Group health plan claim decision timeframes (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
10. [K.A.R. 40-4-34 — Kansas Insurance Department Policy and Procedure Relating to Coordination of Benefits](https://insurance.ks.gov/documents/department/regulations-adopted/article-4/40-4-34-Policy.pdf)
11. [42 CFR 433.139 — Medicaid third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)
12. [32 CFR 199.8 — TRICARE double coverage (eCFR)](https://www.ecfr.gov/current/title-32/subtitle-A/chapter-VII/subchapter-M/part-199/section-199.8)
13. [38 CFR 17.276(d) — CHAMPVA last payer to other health insurance (eCFR)](https://www.ecfr.gov/current/title-38/section-17.276)

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.