---
title: "Cigna / Evernorth ABA coverage in Missouri: the intake guide."
url: "https://carelu.com/payers/cigna-missouri"
markdown_url: "https://carelu.com/payers/cigna-missouri.md"
state: MO (Missouri)
payer: Cigna / Evernorth in Missouri
kind: Commercial insurance
description: "How Cigna / Evernorth covers ABA for Missouri families — the national clinical policy, prior authorization, the RSMo § 376.1224 mandate (the $40K ABA cap through 18, exemptions), Missouri behavior-analyst licensure, and what intake should verify."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

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

_Payer Guide · Cigna · Missouri · Last updated September 2026 · 4 primary sources_

> EN0499 + autism resource guide + the RSMo § 376.1224 mandate layer.

For an intake team in Missouri, a Cigna card means three layers at once: the carrier's national clinical policy, Missouri's autism insurance mandate (RSMo § 376.1224), 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]
- **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:** RSMo § 376.1224 (HB 1311, 2010; expanded 1/1/2020)
- **Mandate age:** No overall age limit stated; the ABA dollar cap applies through age 18
- **Mandate caps:** $40,000/yr ABA (statutory base, CPI-indexed; exceedable with plan approval)
- **Exempt from mandate:** Self-funded private ERISA plans; short-term and limited policies
- **Licensure:** MO Licensed Behavior Analyst (RSMo 337.315, Div. of Professional Registration)

## The national policy, applied in Missouri

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. And unlike some states, Missouri gets the national policy straight: we searched the current EN0499 (effective 5/15/2026) end to end and Missouri appears nowhere — no carve-out, no state-specific criteria — so EN0499 applies to Missouri members except where state law requires otherwise. The legal floor underneath it is the mandate below, which governs fully-insured plans, 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 Missouri. [1][2]

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

Missouri's mandate — enacted by 2010's HB 1311, with the current version applying to plans delivered, issued, continued, or renewed on or after January 1, 2020 (which added developmental and physical disability coverage) — reaches unusually far: beyond ordinary individual and group policies, it covers the state consolidated health care plan, self-insured governmental plans, MEWAs, and self-insured school district health plans established after 1/1/2020. ABA must be ordered by the treating licensed physician or psychologist in a treatment plan, supervised by a board-certified behavior analyst licensed under Chapter 337, and insurers may review the ABA treatment plan no more than once every 6 months unless the provider agrees otherwise. The headline number: ABA carries a $40,000-per-calendar-year cap for individuals through age 18 — statutory base value. Three things soften it: the cap may be exceeded with prior plan approval when additional ABA is medically necessary; it is CPI-indexed (carriers must adjust at least triennially, with the current adjusted figure published annually in the Missouri Register — don't quote $40K as the live number without checking); and other autism treatments (OT/PT/speech, psychiatric, pharmacy) sit outside the cap entirely. Self-funded private ERISA plans remain federally preempted. [3]

## Licensure & rates in Missouri

Missouri requires behavior-analyst licensure: RSMo 337.315 prohibits practicing applied behavior analysis without an LBA (or Licensed Assistant Behavior Analyst) license or an enumerated exception — supervised trainees, licensed psychologists within scope, IDEA school personnel, and students among them. The Behavior Analyst Advisory Board within the State Committee of Psychologists (Division of Professional Registration, RSMo 337.300–337.345) reviews applications, and the mandate itself requires BCBA-supervised, Chapter 337-licensed delivery — so licensure is a coverage requirement, not just a credentialing one. On rates: Cigna does not publish commercial ABA fee schedules for Missouri (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement. Benchmark against MO HealthNet's published fee schedule ($20.13/unit on 97153 at the analyst tier) when modeling. [4]

## Intake gates

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

- **Diagnosis recency**: 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]
- **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 into the treatment plan's goals. Continued treatment requires a repeat standardized assessment within a year. Missouri's mandate names no instrument. [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. Missouri adds nothing for a commercial plan; its telemedicine regulation governs MO HealthNet. [2]
- **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. 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]
- **Age limit** _(plan-dependent)_: 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.
- **Who may diagnose** _(plan-dependent)_: 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.
- **Referral required?** _(plan-dependent)_: 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.
- **Prior-auth decision time** _(plan-dependent)_: 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.

## Delivery and billing rules

Coverage decides whether Cigna / Evernorth in Missouri 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. 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]
- **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. Agency-to-agency transitions with overlapping authorization periods require documented coordination between agencies. [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, 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]
- **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 Missouri

- **Plan funding type:** Fully insured (mandate applies — including MO's unusual reach into governmental and school self-insured plans) vs. self-funded private ERISA (exempt). Ask for the employer and check the card.
- **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 vs. the cap:** The ABA dollar cap runs through age 18 and is CPI-indexed — verify the current adjusted value and year-to-date usage before projecting hours.

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

## Verification of benefits (VOB) data

How Cigna / Evernorth in Missouri 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 | — | — | — | — | — |
| 97152 | Yes | — | — | — | — | — |
| 97153 | Yes | — | — | — | — | — |
| 97154 | Yes | — | — | — | — | — |
| 97155 | Yes | — | — | — | — | — |
| 97156 | Yes | — | — | — | — | — |
| 97157 | Yes | — | — | — | — | — |
| 97158 | Yes | — | — | — | — | — |
| 0362T | Yes | — | — | — | — | — |
| 0373T | Yes | — | — | — | — | — |

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/PA mechanics are published in it. Missouri mandate (RSMo 376.1224): fully-insured plans carry a $40,000/calendar-year ABA cap through age 18 (CPI-indexed statutory base, exceedable with plan approval); self-funded private ERISA plans are exempt. The cap is a benefit-design fact, not a per-code rule — verify plan funding type and the current adjusted cap on the live 271/benefits check.

### Contacts

- **Provider services phone:** 877-279-7603 (Evernorth Autism Care Coordinator team — nonclinical; patient benefits/eligibility, authorization info, and ABA-specific questions) or 800-926-2273 (Evernorth Provider Services — billing, benefits, and eligibility for autism-related treatment)
- **Hours:** Autism Care Coordinator team: Mon-Fri 8:30 AM-5:00 PM CT. Provider Services: Mon-Fri 7:00 AM-7:00 PM CT.
- **Portal:** [Evernorth provider website — Procedure Code Benefit Tool (real-time eligibility/benefit check) and Coverage Confirmation Grid (secure-email benefit verification, 1-business-day turnaround)](https://provider.evernorth.com)

Questions to ask on a verification call:

- Does this plan require prior authorization for ABA treatment codes (97153-97158), or only for the initial assessment codes (97151/97152/0362T)?
- What are the daily/session unit caps for ABA treatment codes under this specific plan?
- Which places of service (home, school, clinic, telehealth) are approved for this member's ABA benefit, and are modifiers required for services delivered outside the clinic?
- Is this a fully-insured Missouri plan subject to the RSMo 376.1224 $40,000/year ABA cap, or a self-funded ERISA plan exempt from the state mandate — and if capped, what is the current adjusted annual maximum?
- Does this payer ID support real-time (vs. batch) 270/271 eligibility responses for this group?

### 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)
- https://revisor.mo.gov/main/OneSection.aspx?section=376.1224 (accessed 2026-07-23)

## Common questions

### Does Cigna cover ABA therapy in Missouri?

Yes — under the carrier's national EN0499 policy for ASD (which applies in Missouri without any state carve-out), layered on Missouri's mandate (RSMo § 376.1224) for fully-insured plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first.

### What does the Missouri autism mandate require?

Coverage of ASD diagnosis and treatment including ABA, with a $40,000-per-year ABA cap through age 18 — a CPI-indexed statutory base that can be exceeded with plan approval when medically necessary. Treatment-plan reviews are limited to once every 6 months, and ABA must be supervised by a Chapter 337-licensed behavior analyst.

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

Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against the MO HealthNet fee schedule, and treat rate-setting as part of contracting.

## Primary sources

1. [Evernorth EN0499 — Intensive Behavioral Interventions (eff. 5/15/2026)](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. [RSMo § 376.1224 (Missouri Revisor of Statutes)](https://revisor.mo.gov/main/OneSection.aspx?section=376.1224)
4. [RSMo § 337.315 — behavior analyst licensure](https://revisor.mo.gov/main/OneSection.aspx?section=337.315)
5. [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)
6. [RSMo 376.1363 — Utilization review decisions, procedures](https://revisor.mo.gov/main/OneSection.aspx?section=376.1363)
7. [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)
8. [20 CSR 400-2.030 — Missouri Group Coordination of Benefits](https://www.sos.mo.gov/cmsimages/adrules/csr/current/20csr/20c400-2.pdf)
9. [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)
10. [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)
11. [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.