---
title: "Cigna / Evernorth ABA coverage in Ohio: the intake guide."
url: "https://carelu.com/payers/cigna-ohio"
markdown_url: "https://carelu.com/payers/cigna-ohio.md"
state: OH (Ohio)
payer: Cigna / Evernorth in Ohio
kind: Commercial insurance
description: "How Cigna / Evernorth covers ABA for Ohio families — the national clinical policy, prior authorization, the Ohio R.C. § 3923.84 mandate (ages, caps, exemptions), Ohio behavior-analyst licensure, and what intake should verify."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

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

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

> EN0499 + autism resource guide + the Ohio R.C. § 3923.84 mandate layer.

For an intake team in Ohio, a Cigna card means three layers at once: the carrier's national clinical policy, Ohio's autism insurance mandate (Ohio R.C. § 3923.84), 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) [2][1]
- **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:** Ohio R.C. § 3923.84
- **Mandate age:** Service floors apply under age 14
- **Mandate caps:** Floors, not caps: ≥20 hrs/wk ABA-inclusive intervention
- **Exempt from mandate:** Limited-benefit policy types; self-funded ERISA
- **Licensure:** Certified Ohio Behavior Analyst (COBA, Board of Psychology)

## The national policy, applied in Ohio

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 Ohio 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 Ohio. [1][2]

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

Ohio’s mandate (HB 463, 2017; R.C. 3923.84, with § 1751.84 for HMOs) sets service floors for insureds under age 14 rather than caps: at least 20 hours/week of “clinical therapeutic intervention” — explicitly defined to include applied behavior analysis — plus 20 visits/year each for speech and OT and 30 outpatient mental-health visits/year. Mandated ABA must be provided by or under the supervision of a Certified Ohio Behavior Analyst (or licensed psychologist/counselor/social worker/MFT), and since a March 2025 amendment, clinical nurse specialists and certified nurse practitioners can also prescribe or order ASD services. Dollar limits and cost-sharing can’t be less favorable than substantially all medical/surgical benefits; self-funded ERISA plans are exempt by preemption, and carriers in practice authorize on medical necessity rather than the statutory hour counts. [3]

## No Ohio-specific Cigna policy exists

We checked: Cigna / Evernorth publishes no Ohio-specific ABA policy, form, or supplement — the national policy plus the state mandate is the whole picture. That’s worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where Ohio-specific answers come from, not a carrier document. [1]

## Licensure & rates in Ohio

Ohio’s COBA certificate (ORC Chapter 4783, Ohio Board of Psychology, with a direct BCBA pathway) is baked into the mandate itself — R.C. 3923.84 conditions mandated ABA on COBA-supervised delivery — so COBA status is a commercial coverage requirement in Ohio, not just a Medicaid credentialing detail. On rates: Cigna does not publish commercial ABA fee schedules for Ohio (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement, so treat rate expectations as a contracting conversation, not a lookup. [4]

## Intake gates

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

- **Diagnosis recency**: EN0499 puts no expiry on the ASD diagnosis, but it requires the name, credentials and licensure type of the diagnosing clinician and the date on which the diagnosis was most recently made — and a diagnosis termed provisional, proposed, potential, at risk of or rule out is not a confirmed diagnosis, nor is IDEA educational identification. The recency clocks sit on the data instead: the standardized assessment instrument must have been administered within 60 days prior to the start of treatment, quantitative baseline data collected within 60 days prior to start, current data within 60 days of the authorization request, a standardized instrument completed no more than one year prior for continued treatment, and a fresh standardized assessment after any break in treatment greater than 60 calendar days. [1]
- **Who may diagnose**: The ASD diagnosis (ICD-10 F84.0–F84.9 except F84.2, Rett syndrome) must be made under DSM-5-TR criteria 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 performed by a Board Certified Behavior Analyst, a Licensed Behavior Analyst, or a mental health clinician licensed to practice independently who has documented training in ABA. [1]
- **Diagnostic tools required**: EN0499 mandates no single named instrument. It requires a reliable, valid and standardized assessment instrument measuring the DSM-5-TR ASD domains — social communication and social interaction, and restricted, repetitive patterns of behavior, interests or activities — completed in its entirety and as designed, by someone trained to administer and interpret it, with reliability and validity established for the population tested, in the most current edition rather than an obsolete one (the policy’s own example: Vineland-3, not Vineland-II). The report must carry the date of administration, the respondent or participant name, the form type where applicable, and standardized scores and score tables or scoring grids. [1]
- **Referral required?**: No referral, order or prescription is required under EN0499. Cigna’s notable front-door change is on authorization: per the Evernorth autism resource guide, prior authorization is no longer required for assessment codes 97151, 97152 or 0362T with a diagnosis of autism, as long as the provider is independently licensed or a BCBA and the member’s policy covers ABA — submit the claims and they are evaluated for payment. Treatment authorization requires the completed assessment and treatment plan attached to the Applied Behavior Analysis Prior Authorization Form. For a fully insured Ohio plan the state mandate adds an ordering requirement the carrier policies do not: R.C. 3923.84 makes coverage contingent on the services being prescribed or ordered by a psychologist trained in autism, a developmental pediatrician, or — since Senate Bill 196 took effect March 20, 2025 — a clinical nurse specialist or certified nurse practitioner specialising in pediatric health. Prior authorization is written into the mandate as the other condition of coverage. Non-grandfathered individual and small-group plans are carved out, and self-funded ERISA plans sit outside state insurance law. [2][1][3]
- **Telehealth**: All ABA CPT codes are covered telehealth services per the Evernorth autism resource guide, and EN0499 allows delivery in person, via telehealth, or as a hybrid — the modality chosen on individual characteristics, the treatment plan, caregiver participation, environment, evidence of efficacy and safety, and technological requirements. The requirement that the ABA provider remain in line of sight and close proximity to the individual expressly does not apply to telehealth services. Where treatment is delivered in settings with additional behavioral expectations, telehealth included, the plan must document that the service still meets the definition of direct treatment and direct engagement. [2][1]
- **Age limit** _(plan-dependent)_: EN0499 sets no age cap on ABA — its glossary, following CASP 2024, states that access to focused intervention "should not be restricted by age, cognitive level, diagnosis, or co-occurring conditions." Age terms come from the member’s benefit plan document, which supersedes the coverage policy, and from any controlling state mandate. Ohio sets a floor rather than a cap: R.C. 3923.84 requires at least 20 hours a week of clinical therapeutic intervention for an insured under age fourteen and says the section "shall not be construed as limiting benefits that are otherwise available." Non-grandfathered individual and small-group plans and limited-benefit policies are carved out by name, and self-funded ERISA plans are exempt by preemption. [1][3]
  - Ask the plan: Live benefits verification, or the Evernorth Autism Care Coordinator team on 877.279.7603 — establish fully insured vs. self-funded ERISA first.
- **Prior-auth decision time** _(plan-dependent)_: For insured Ohio plans the state clock is faster than the federal floor. When the request is submitted electronically, the insurer “shall respond to all prior authorization requests within forty-eight hours for urgent care services, or ten calendar days for any prior authorization request that is not for an urgent care service, of the time the request is received” (R.C. 3923.041 for sickness-and-accident insurers and public employee benefit plans; R.C. 1751.72 for health insuring corporations). An incomplete request must get a reply naming the missing information. Plans outside those statutes, such as a self-funded private employer plan, are held to the federal floor: pre-service decisions “not later than 15 days after receipt of the claim,” one 15-day extension, and urgent care “not later than 72 hours after receipt” (29 CFR 2560.503-1). The same floor applies to non-grandfathered individual and marketplace plans (45 CFR 147.136). [5][6][7][8]
  - Ask the plan: Evernorth Behavioral Health / Cigna (number on the member ID card): whether the plan is insured in Ohio (R.C. 3923.041 / 1751.72 apply), self-funded (ERISA floor) or grandfathered; the plan’s own standard and urgent turnaround for ABA; and how far ahead of expiry a reauthorization must be filed.
- **Other insurance (who pays first)** _(plan-dependent)_: Ohio’s COB rule sets the order for a child on both parents’ plans: “The plan of the parent whose birthday falls earlier in the calendar year is the primary plan”; if the birthdays match, the plan that has covered a parent longer goes first. For parents who are divorced, separated or not living together, a court decree assigning health costs controls. Without one, the order is the custodial parent’s plan, then the custodial parent’s spouse’s, then the non-custodial parent’s, then the non-custodial parent’s spouse’s (OAC 3901-8-01). That rule governs contracts issued in Ohio. Whether a self-funded employer plan follows it or its own plan document’s COB clause is a question for that plan. Public coverage pays after this plan. Ohio Medicaid “must be the last payer” (OAC 5160-1-08). TRICARE “pays after all other health insurance, except for” Medicaid. CHAMPVA “is always the secondary payer, except to Medicaid.” If this plan denies because its rules were not followed, including its prior authorization, TRICARE “may also deny the claim.” So get this plan’s authorization even when a public program is secondary. [9][10][11][12]
  - Ask the plan: Ask the family for both parents’ cards and birth dates, and ask the employer or HR whether each plan is fully insured and issued in Ohio (OAC 3901-8-01 order applies) or self-funded (the plan document’s COB clause applies).

## Delivery and billing rules

Coverage decides whether Cigna / Evernorth in Ohio 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**: Case supervision is performed by a BCBA, a Licensed Behavior Analyst, or a mental health professional licensed to practice independently with documented training in ABA. Direct case supervision — occurring concurrently with direct treatment, with the BCBA face-to-face with the individual and with either the RBT or the BCaBA — plus indirect case supervision runs at the generally 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. The name and credentials of the person providing supervision must be documented, and supervisory services must coincide with the AMA CPT code descriptions. [1]
- **Concurrent billing (97153 + 97155)**: Only one provider can bill for a unit of time, with one exception: CPT codes 97153, 97154 and 97155 during direct supervision, when the BCBA or qualified health care professional directs the technician and both are face-to-face with the patient at the same time. Separately, ABA treatment is not covered or reimbursable when delivered to the same individual at the same time as any other treatment modality — the policy’s own examples are ABA and speech therapy, or ABA and occupational therapy. [2][1]
- **Daily limits / MUEs**: Cigna publishes no per-day unit ceiling. All ABA CPT codes bill in 15-minute increments, and all ABA services must be billed with 97151–97158, 0362T and 0373T only. The published limits are structural rather than daily: planned treatment intensity must reflect the severity of the impairments, the goals of treatment and the response to treatment across all settings, and case supervision sits at one to two hours per ten hours of direct treatment. 0362T and 0373T are each reported on a single technician’s face-to-face time, not the combined time of multiple technicians. [2][1]
- **Session-note signature**: A separate written record is expected for each individual receiving ABA, corresponding with each service billed under its CPT code, carrying at least: the start date and time and end date and time for each service, the location of service delivery, the focus of service, a detailed description of the intervention conducted during the time of service, the individuals present, the specific service delivered (direct service, supervision, stakeholder training), and the name, credential where applicable, and signature of the ABA provider who rendered the service. [1]
- **Place of service**: Treatment goals must be defined and measured across all settings and environments where treatment will occur — home, clinic, school, community — and quantitative data must be obtained and reported separately by location for each behavior and skill. Services considered primarily educational or vocational in nature, or related to academic or work performance, are not covered or reimbursable. Where services are delivered in environments that carry additional or alternative behavioral expectations (academic setting, vocational placement, telehealth), the plan must document that the service still meets the direct-treatment definition and is not replacing activities that belong to that setting. [1]
- **Bill as provider**: Evernorth does not credential non-licensed or non-certified staff — their services must be billed under the supervising provider. On a CMS-1500 the rendering provider prints their name in box 31 and only a BCBA or other licensed provider is listed in box 33; electronic claims go to Evernorth payer ID 62308. Per the autism resource guide’s code table, 97152, 97153 and 97154 may be provided by a BCaBA or technician but billed only by a BCBA-D, BCBA or licensed mental health provider, while 97151, 97155, 97156, 97157, 97158, 0362T and 0373T are both provided and billed by a BCBA-D, BCBA or licensed mental health provider. [2]

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

- **Plan funding type:** Fully insured (mandate applies) vs. self-funded ERISA (exempt) — it decides which rulebook governs. 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:** Where the mandate carries age terms, flag edge cases for the 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 Ohio 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. Ohio mandate (R.C. 3923.84): fully-insured plans set service FLOORS for insureds under age 14 (>=20 hrs/wk ABA-inclusive clinical therapeutic intervention), COBA-supervised; self-funded ERISA plans are exempt. Verify plan funding type on the live benefits check.

### Contacts

- **Provider services phone:** (800) 882-4462
- **Portal:** [CignaforHCP](https://cignaforhcp.cigna.com)
- **Fax:** (866) 873-8279

Questions to ask on a verification call:

- Does ABA require prior authorization on this specific plan, and what is the process?
- What are the daily or weekly unit caps for each ABA code?
- What POS codes and telehealth modifiers are accepted for ABA?
- Do you require a licensure-tier billing modifier?
- Is this member's plan fully-insured or self-funded? Ohio mandate (R.C. 3923.84): fully-insured plans set service FLOORS for insureds under age 14 (>=20 hrs/wk ABA-inclusive clinical therapeutic intervention), COBA-supervised; self-funded ERISA plans are exempt. Verify plan funding type on the live benefits check.

### 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://codes.findlaw.com/oh/title-xxxix-insurance/oh-rev-code-sect-3923-84/ (accessed 2026-07-23)
- https://www.cigna.com/health-care-providers/coverage-and-claims/precertification (accessed 2026-07-23)

## Common questions

### Does Cigna cover ABA therapy in Ohio?

Yes — under the carrier's national policy for ASD, layered on Ohio's mandate (Ohio R.C. § 3923.84) for fully-insured plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first.

### What does the Ohio autism mandate require?

Ohio’s mandate (HB 463, 2017; R.C. See the mandate section above for ages, caps, and exemptions — and remember federal parity limits how hard the numeric caps can be enforced against group plans.

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

Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against the Ohio Medicaid fee schedule where one exists, 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. [Ohio Rev. Code § 3923.84 (autism coverage mandate)](https://codes.findlaw.com/oh/title-xxxix-insurance/oh-rev-code-sect-3923-84/)
4. [Ohio Admin. Code 4783-4-01 — COBA requirements](https://www.law.cornell.edu/regulations/ohio/Ohio-Admin-Code-4783-4-01)
5. [R.C. 3923.041 — prior authorization: sickness and accident insurers and public employee benefit plans](https://codes.ohio.gov/ohio-revised-code/section-3923.041)
6. [R.C. 1751.72 — prior authorization: health insuring corporations](https://codes.ohio.gov/ohio-revised-code/section-1751.72)
7. [29 CFR 2560.503-1 — ERISA claims procedure (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
8. [45 CFR 147.136 — internal claims and appeals, group and individual coverage (eCFR)](https://www.ecfr.gov/current/title-45/section-147.136)
9. [OAC 3901-8-01 — Coordination of benefits (order of benefit determination)](https://codes.ohio.gov/ohio-administrative-code/rule-3901-8-01)
10. [OAC 5160-1-08 — Medicaid coordination of benefits](https://codes.ohio.gov/ohio-administrative-code/rule-5160-1-08)
11. [TRICARE — Using Other Health Insurance](https://www.tricare.mil/Plans/OHI)
12. [VA — CHAMPVA: Information for Outpatient Providers (IB 10-1587, updated 9/20/2023)](https://www.va.gov/COMMUNITYCARE/docs/pubfiles/factsheets/FactSheet_01-20.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.