---
title: "Cigna / Evernorth ABA coverage in Maryland: the intake guide."
url: "https://carelu.com/payers/cigna-maryland"
markdown_url: "https://carelu.com/payers/cigna-maryland.md"
state: MD (Maryland)
payer: Cigna / Evernorth in Maryland
kind: Commercial insurance
description: "How Cigna / Evernorth covers ABA for Maryland families — the national clinical policy, prior authorization, Maryland's habilitative services mandate (Md. Ins. § 15-835 + COMAR 31.10.39.03 with 25/10 hour floors), Maryland LBA licensure, and what intake should verify."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

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

_Payer Guide · Cigna · Maryland · Last updated September 2026 · 5 primary sources_

> EN0499 + autism resource guide + Maryland's habilitative-services mandate with 25/10-hr floors.

For an intake team in Maryland, a Cigna card means three layers at once: the carrier's national clinical policy, Maryland's habilitative-services mandate (Md. Code Ann., Insurance § 15-835, implemented by COMAR 31.10.39.03), and the plan's funding type deciding which of the two actually binds. Maryland's mandate is unusual — it carries hour FLOORS below which ABA can't be denied. This guide stacks the layers 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]
- **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) [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:** Md. Ins. § 15-835 + COMAR 31.10.39.03 (habilitative services)
- **Mandate age:** Through at least the month the enrollee turns 19; hour floors span 18 months–18 years
- **Mandate floors:** No denial solely on hours up to 25 hrs/wk (18 mo–5 yrs) or 10 hrs/wk (6–18); no dollar cap
- **Exempt from mandate:** Self-funded ERISA plans; early-intervention/school-delivered services
- **Licensure:** MD Licensed Behavior Analyst (Board of Professional Counselors & Therapists)

## The national policy, applied in Maryland

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 Maryland 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 Maryland. [1][2]

## The Maryland mandate: hour floors, not caps

Maryland has no standalone "autism mandate" — ABA is covered as a habilitative service for children with ASD under Insurance § 15-835, with the ABA-specific rules in COMAR 31.10.39.03 (effective April 3, 2014). The statute requires Maryland-regulated insurers, nonprofit health service plans, and HMOs to cover habilitative services until at least the end of the month the enrollee turns 19. The COMAR layer is where the teeth are: ABA may not be denied solely on the basis of prescribed hours up to 25 hours/week for ages 18 months through 5 years and up to 10 hours/week for ages 6 through 18 — with additional hours authorized when medically necessary — and ABA may not be denied as experimental or investigational. There is no dollar cap. The entry requirements: a comprehensive evaluation, a prescription with treatment goals from the PCP or a specialty physician, and annual review by the prescriber — so the prescription and its renewal date are intake data. Carriers aren't required to reimburse services delivered through early intervention or the schools, and self-funded ERISA plans are exempt — for those, MHPAEA parity is the fallback lever, and the hour floors don't apply. [3][4]

## No Maryland-specific Cigna policy exists

We checked the current EN0499 (effective May 15, 2026) in full: it contains no Maryland entry, carve-out, or state-specific exhibit — only the generic clause that a controlling federal or state coverage mandate supersedes the policy. So for fully-insured Cigna members in Maryland, the § 15-835 / COMAR 31.10.39 protections layer directly on top of the national policy without any Cigna-published Maryland supplement, and benefits verification (funding type, mandate applicability) is where Maryland-specific answers come from — not a carrier document. [1]

## Licensure & rates in Maryland

Maryland has required licensure to practice behavior analysis since January 2015: the Licensed Behavior Analyst (LBA) credential, administered by the Behavior Analyst Advisory Committee of the State Board of Professional Counselors and Therapists (Health Occupations Title 17, Subtitle 6A; COMAR 10.58.16), built on current BACB certification, a qualifying master's degree, and a criminal-history check. The mandate's COMAR criteria likewise expect licensed delivery. On rates: Cigna does not publish commercial ABA fee schedules for Maryland (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement. Maryland's Medicaid fee schedule (effective February 1, 2026 — e.g., 97153 at $24.41/15-min BCBA tier) is the public benchmark to negotiate against. [5]

## Intake gates

The questions that decide whether a family can start with Cigna / Evernorth in Maryland, and what they have to bring.

- **Diagnosis recency**: Cigna's recency rule attaches to the standardized assessment rather than to the diagnosis itself, and it is tight. Initiation requires a standardized, validated instrument in its current edition administered within 60 days before treatment start. Continued treatment needs an updated plan with current data no more than 60 days old, a repeat standardized assessment within a year, and a re-assessment after any break in service longer than 60 days. If the family's most recent testing is older than 60 days, plan to administer during your assessment window — which Cigna lets you open without prior authorization. [1]
- **Diagnostic tools required**: A standardized, validated instrument in its current edition — the policy gives Vineland-3 as the example rather than a closed list — administered within 60 days before treatment start, with the deficits it measures mapped to DSM-5-TR ASD domains and carried through into the treatment plan's goals. Continued treatment requires a repeat standardized assessment within a year. [1]
- **Telehealth**: The most permissive position in this directory: Cigna's March 2025 autism resource guide states that all ABA CPT codes are covered telehealth services, with the delivery model — in person, telehealth or hybrid — chosen on the individual's needs. Maryland adds nothing here for a commercial plan; the 25 percent in-person floor in PT 60-26 is a Medicaid rule and does not reach a Cigna commercial member. [2]
- **Age limit** _(plan-dependent)_: Two answers, and plan funding type picks between them. The carrier's national ABA policy states no age limit. Maryland's habilitative-services mandate does: for Maryland-regulated insurers, nonprofit health service plans and HMOs, habilitative services must be covered “until at least the end of the month the enrollee turns 19,” and COMAR 31.10.39.03 pins its no-denial hour floors to age bands — up to 25 hours/week for ages 18 months through 5 years and up to 10 hours/week for ages 6 through 18, with more when medically necessary. Self-funded ERISA plans are exempt from all of it, so establish funding type before quoting either bound. [3][4]
  - Ask the plan: Benefits verification on the specific plan, via the payer portal or the number on the member’s card — ask whether the plan is Maryland-regulated (an insurer, nonprofit health service plan or HMO, which the habilitative-services mandate and COMAR 31.10.39.03 age bands reach) or a self-funded ERISA plan (exempt). If it is self-funded, ask what age limit and weekly hour limit the plan document sets for ABA before you quote either bound to the family.
- **Referral required?** _(plan-dependent)_: On a fully-insured Maryland plan, yes — and it is a prescription, not a note. COMAR 31.10.39.03 conditions the mandated benefit on a comprehensive evaluation, a prescription with treatment goals from the PCP or a specialty physician, and annual review by the prescriber. Capture the prescriber and the prescription date at intake, and diary the annual renewal: a lapsed prescription is a coverage problem, not a paperwork one. Self-funded ERISA plans are outside the mandate, and for those the carrier's own authorization requirements are the only gate. [3][4]
  - Ask the plan: Benefits verification on the specific plan, via the payer portal or the number on the member’s card — confirm funding type first. On a Maryland-regulated plan, capture the prescriber and prescription date and diary the annual prescriber review COMAR 31.10.39.03 requires. On a self-funded ERISA plan, ask the carrier whether it requires a referral or prescription at all, since the mandate does not reach it and only the carrier’s own authorization rules apply.
- **Prior-auth decision time** _(plan-dependent)_: Evernorth (Cigna’s behavioral arm) makes “coverage determinations in accordance with the time frames required under applicable law,” so the clock depends on how the plan is funded. If the child’s plan is fully insured in Maryland, Insurance §15-10B-06 sets the clock: an initial request is decided “within 2 working days after receipt of the information necessary to make the determination,” “additional visits or days of care submitted as part of an existing course of treatment or treatment plan within 1 working day,” emergency requests within 24 hours, and a reviewer missing information must say so within 3 calendar days. Maryland’s teeth: “If a private review agent fails to make a determination within the time limits required under this section, the request shall be deemed approved.” Mental-health treatment plans must be accepted on the MIA uniform treatment plan form. If the employer self-funds, ERISA’s floor applies instead: pre-service decisions “not later than 15 days after receipt of the claim” (one 15-day extension allowed), urgent claims within 72 hours. Evernorth’s own lead time: “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.” [6][2][7][8]
  - Ask the plan: the Evernorth Autism Care Coordinator team (877-279-7603) or the ID-card number — ask whether the plan is fully insured in Maryland or self-funded
- **Other insurance (who pays first)** _(plan-dependent)_: Evernorth follows “the National Association of Insurance Commissioners guidelines about the industry standard of order of benefit determination subject to applicable law and the terms of the benefit plan.” For a child of married parents living together, “The plan of the parent whose birthday falls earlier in the calendar year is primary to the plan of the parent whose birthday falls later in the year” (same birthday: the plan in effect longer); for separated or divorced parents, a court decree first, then the custodial parent’s plan, the custodial parent’s spouse’s, the non-custodial parent’s, and that parent’s spouse’s. Bill the primary first, then Cigna (payer ID 62308, or paper with the primary’s EOB). Maryland has not yet adopted a COB regulation: the Insurance Administration says contract COB provisions “have historically been reviewed for consistency with the NAIC Model, but the Model has not been formally adopted to date,” and its draft COMAR 31.10.53 (comments closed August 2026) would codify the NAIC birthday rule (“The plan of the parent whose birthday falls earlier in the calendar year is the primary plan”) and exclude Medicaid from the definition of a plan — so Maryland Medicaid always pays after the commercial plan. [6][9][10]
  - Ask the plan: the carrier’s eligibility response (Availity or the ID-card number) for an other-insurance record, and both parents’ birth dates and custody arrangements at intake; a self-funded plan follows its own plan document
- **Who may diagnose** _(ask the plan)_: EN0499 as quoted in this guide sets the credential bar for who performs the ABA assessment and supervises the case — an independently licensed provider or a BCBA — rather than naming who may make the ASD diagnosis. The diagnosis itself must be a DSM-5-TR autism spectrum diagnosis, with Rett syndrome (F84.2) excluded. [1][2]
  - Ask the plan: Evernorth Behavioral Health provider services (the behavioral health number on the member's card) — ask which diagnosing credentials EN0499 accepts before you rely on a diagnosis from a non-doctoral clinician.

## Delivery and billing rules

Coverage decides whether Cigna / Evernorth in Maryland 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**: Assessment and case supervision must come from a BCBA, a licensed behavior analyst, or an independently licensed clinician with documented ABA training, with direct supervision at the standard 1–2 hours per 10 hours of direct treatment. Evernorth does not credential non-licensed staff. In Maryland the supervising analyst must additionally hold the state Licensed Behavior Analyst credential, required to practice behavior analysis since January 2015. [1][5]
- **Concurrent billing (97153 + 97155)**: Restrictive, and the restriction is about other therapies as much as about ABA codes. EN0499 does not cover ABA delivered at the same time as another therapy (speech, OT) to the same child, and only one provider may bill a unit of time, with the standard supervision exceptions. Where a family is transitioning between ABA agencies, overlapping authorization periods require documented coordination between the agencies — so the outgoing provider's details belong on the intake form. [1]
- **Session-note signature**: Every session note needs the date, start and end times, location, focus, a detailed description of the intervention, the persons present, the service type, and the rendering provider's name, credential and signature. No countersignature requirement and no signing deadline are published. [1]
- **Bill as provider**: Evernorth does not credential non-licensed staff, so RBT-delivered services bill under the supervising provider. The treatment plan must name a credentialed supervisor. [1]
- **Daily limits / MUEs** _(ask the plan)_: Not published as a per-day unit ceiling. EN0499 bounds the day from a different direction: ABA is not covered when delivered at the same time as another therapy to the same child, and only one provider can bill a unit of time, with the standard supervision exceptions. Requested intensity is set in the treatment plan and authorized on the ABA PA form rather than against a published cap. [1]
  - Ask the plan: The treatment authorization itself, and Evernorth Behavioral Health provider services (the behavioral health number on the member's card) — ask whether any per-day MUE is applied to ABA codes on this plan.
- **Place of service** _(ask the plan)_: Not published as a payable-settings list. Two sourced facts bear on setting nonetheless: the treatment plan must carry dated baseline data per setting, so settings are declared and measured rather than assumed; and every session note must record the location. Whether a given setting is payable is a plan-benefit question. [1]
  - Ask the plan: Benefits verification on the specific plan — ask which places of service are payable for ABA, and whether school-based delivery is excluded before you write school goals.

## What intake should collect for Cigna / Evernorth in Maryland

- **Plan funding type:** Fully insured (mandate + hour floors apply) vs. self-funded ERISA (exempt) — it decides which rulebook governs. Ask for the employer and check the card.
- **ABA prescription + goals:** COMAR requires a prescription with treatment goals from the PCP or a specialty physician, reviewed annually — capture the prescriber and date.
- **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.

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

## Verification of benefits (VOB) data

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

### EDI routing

- **Payer ID (Availity):** 62308
- **Payer ID (Change Healthcare / Optum):** 62308
- **Supports 270/271 eligibility:** Yes
- **Real-time 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 or Maryland-specific exhibit are published in it. QA 2026-07-23: paRequired downgraded verified->unverified — EN0499, re-read in full, contains no prior-authorization/precertification language, so the "(per EN0499)" attribution cannot support the per-code PA verdicts. The three assessment "Not required" values are separately corroborated by the Cigna Autism Resource Guide (cited at the EDI level); the treatment-code "Required" verdicts remain to be confirmed with Cigna/Evernorth provider services.

### Contacts

- **Provider services phone:** 877.279.7603
- **Hours:** Monday–Friday, 8:30 a.m.–5:00 p.m. CT (Autism Care Coordinator team — benefits, eligibility, and authorization questions). A separate Provider Services department at 800.926.2273 handles billing/demographic questions, Monday–Friday 7:00 a.m.–7:00 p.m. CT.
- **Portal:** [Evernorth provider website (Procedure Code Benefit Tool)](https://provider.evernorth.com)

Questions to ask on a verification call:

- What are the daily or weekly unit caps for this member's plan across the ABA code set (97151–97158, 0362T, 0373T)?
- Which places of service (home, office, school, telehealth) are authorized under this plan?
- Are telehealth modifiers (GT or 95) accepted for any ABA codes, and if so which ones?
- Are licensure-tier billing modifiers required to distinguish BCBA vs. BCaBA vs. RBT/BT rendering providers?

### VOB data sources

- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.uhcprovider.com/content/dam/provider/docs/public/resources/edi/Payer-List-UHC-Affiliates-Strategic-Alliances.pdf (accessed 2026-07-23)
- https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/autism-resource-guide.pdf (accessed 2026-07-23)
- https://pverify.com/payer-list/ (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)
- 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 Maryland?

Yes — under the carrier's national policy for ASD (EN0499, with no PA on assessment codes), layered on Maryland's habilitative-services mandate for fully-insured plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first.

### What does the Maryland mandate require for ABA?

For fully-insured plans: coverage of habilitative services through at least the month the enrollee turns 19, no denial of ABA solely on prescribed hours up to 25 hrs/week (ages 18 months–5) or 10 hrs/week (ages 6–18), no experimental/investigational denials, and no dollar cap — entered via a comprehensive evaluation plus a physician prescription reviewed annually.

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

Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against Maryland Medicaid's February 2026 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. [Md. Insurance Article § 15-835 (Maryland General Assembly)](https://mgaleg.maryland.gov/mgawebsite/Laws/StatuteText?article=gin&section=15-835&enactments=false)
4. [Optum BH803ABA State Mandates — COMAR 31.10.39.03 criteria (corroborating text)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/scc/ABA_SCC_SM.pdf)
5. [MDH Board of Professional Counselors & Therapists — Behavior Analyst License](https://health.maryland.gov/bopc/pages/analysts.aspx)
6. [Evernorth Behavioral Health Administrative Guidelines (March 2026, PCOMM-2026-191)](https://static.evernorth.com/assets/evernorth/provider/pdf/resourceLibrary/behavioral/ebh-provider-admin-guide.pdf)
7. [Md. Code, Insurance §15-10B-06 — private review agent determinations](https://mgaleg.maryland.gov/mgawebsite/Laws/StatuteText?article=gin&section=15-10B-06&enactments=false)
8. [eCFR — 29 CFR 2560.503-1(f)(2), ERISA claims procedure timeframes](https://www.ecfr.gov/current/title-29/subtitle-B/chapter-XXV/subchapter-F/part-2560/section-2560.503-1)
9. [Maryland Insurance Administration — Regulatory Activity (NAIC COB model not yet adopted)](https://insurance.maryland.gov/Pages/newscenter/RegulatoryActivity.aspx)
10. [MIA draft COMAR 31.10.53 Coordination of Benefits (posted July 2026)](https://insurance.maryland.gov/Documents/newscenter/legislativeinformation/3.10.53-Draft-712026.pdf)

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.