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

Cigna's recency rule attaches to the standardized assessment rather than to the diagnosis, and it is tight: initiation requires a standardized, validated instrument in its current edition administered within 60 days before treatment start. Continued treatment needs current data no more than 60 days old, a repeat standardized assessment within a year, and a re-assessment after any break longer than 60 days. Missouri's mandate sets no diagnosis-recency rule; its six-month clock governs plan review, not the age of the evaluation.^[1][3]

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 into the treatment plan's goals. Continued treatment requires a repeat standardized assessment within a year. Missouri's mandate names no instrument.^[1]

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. Missouri adds nothing for a commercial plan; its telemedicine regulation governs MO HealthNet.^[2]

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. Missouri's COB rule (20 CSR 400-2.030) governs fully insured group plans: when parents are not separated or divorced, "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" (same birthday: the plan that covered the parent longer); 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)).^{[5][8][9][10][11]}

The mandate sets no overall age limit on autism coverage — what it ages out is the dollar cap. RSMo § 376.1224 subjects ABA to “a maximum benefit of forty thousand dollars per calendar year for individuals through eighteen years of age,” a statutory base that is CPI-indexed (the Department of Commerce and Insurance publishes the adjusted figure annually). Coverage required under the section other than ABA “shall not be subject to the age and dollar limitations described in this subsection,” so OT, PT, speech, psychiatric and pharmacy care for autism carry no age cut-off and no dollar cap. Self-funded private ERISA plans are preempted from all of it; note Missouri's unusual reach into the state consolidated health care plan, self-insured governmental plans, MEWAs and self-insured school-district plans established on or after 1/1/2020.^[3]

Ask the plan: Benefits verification on the specific plan, via the payer portal or the number on the member’s card — ask whether RSMo § 376.1224 reaches this plan (it reaches fully-insured plans, the state consolidated health care plan, self-insured governmental plans, MEWAs and self-insured school-district plans established on or after 1/1/2020, but not private self-funded ERISA plans), and what the plan applies as this year’s dollar cap. The Missouri Department of Commerce and Insurance publishes the CPI-adjusted figure annually — quote that year’s number, never the $40,000 statutory base.

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 must be DSM-5-TR autism spectrum, with Rett syndrome (F84.2) excluded. On a plan the Missouri mandate reaches, the ABA must additionally be ordered by the treating licensed physician or psychologist, which is the narrower and more operationally important list.^[1][2][3]

Ask the plan: Evernorth Behavioral Health provider services (the behavioral health number on the member's card) — ask which diagnosing credentials EN0499 accepts before relying on a diagnosis from a non-doctoral clinician.

Yes on a plan the mandate reaches, and the statute is specific about who writes it: ABA “must be ordered by the treating licensed physician or psychologist” in a treatment plan, and must be supervised by a board-certified behavior analyst licensed under chapter 337. Capture the ordering physician or psychologist and the treatment plan they signed. Two Missouri rules work in the provider's favour once the order exists: the carrier may review the treatment plan no more than once every six months unless the provider agrees otherwise, and the cost of obtaining any review or treatment plan is borne by the plan. Self-funded private ERISA plans are outside the statute.^[3]

Ask the plan: Benefits verification on the specific plan, via the payer portal or the number on the member’s card — confirm first whether RSMo § 376.1224 reaches this plan. Where it does, capture the ordering licensed physician or psychologist and the treatment plan they signed, and the supervising chapter 337 licensed behavior analyst. Where it does not (a private self-funded ERISA plan), ask the carrier whether it requires a physician or psychologist order and in what form.

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. Missouri fully insured plans are bound by RSMo 376.1363: a carrier "shall make the determination within thirty-six hours, which shall include one working day, of obtaining all necessary information," with an approval phoned or sent electronically to the provider within 24 hours; concurrent review (continuing an approved course) is decided "within one working day of obtaining all necessary information." The clock starts when the file is complete, not when the form lands. Self-funded ERISA plans are outside state law and follow 29 CFR 2560.503-1: a pre-service decision "not later than 15 days after receipt of the claim" (one 15-day extension), 72 hours for urgent care, and an urgent extension request decided within 24 hours if made at least 24 hours before the approval expires.^[5][2][6][7]

Ask the plan: Evernorth Behavioral Health / Cigna Autism Care Coordinator team, 877.279.7603: confirm whether the plan is fully insured or self-funded, which sets the legal decision clock.

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. Missouri makes the licence a coverage condition: § 376.1224 requires ABA to be supervised by a board-certified behavior analyst licensed under chapter 337.^[1][3][4]

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. Agency-to-agency transitions with overlapping authorization periods require documented coordination between agencies.^[1]

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]

Evernorth does not credential non-licensed staff, so RBT-delivered services bill under the supervising provider, and the treatment plan must name a credentialed supervisor. Missouri's mandate points the same way from the statutory side: reimbursement runs to the autism service provider or the entity the supervising board-certified behavior analyst works for, and expressly covers line-therapist services under that supervision.^[1][3]

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.

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.