---
title: "Cigna / Evernorth ABA coverage in Utah: the intake guide."
url: "https://carelu.com/payers/cigna-utah"
markdown_url: "https://carelu.com/payers/cigna-utah.md"
state: UT (Utah)
payer: Cigna / Evernorth in Utah
kind: Commercial insurance
description: "How Cigna / Evernorth covers ABA for Utah families — the national EN0499 policy, prior authorization, the Utah Code § 31A-22-642 mandate (markets, ages, caps, exemptions), Utah behavior-analyst licensure, and what intake should verify."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

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

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

> EN0499 + autism resource guide + the Utah Code § 31A-22-642 mandate layer.

For an intake team in Utah, a Cigna card means three layers at once: the carrier's national clinical policy, Utah's autism insurance mandate (Utah Code § 31A-22-642), and the plan's market segment and funding type deciding which of the two actually binds. This guide stacks them in order — and in Utah, the market-segment question comes first, because the mandate covers individual and large-group plans but not small group.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment:** Not published / unverified. Verify via: Cigna/Evernorth's precertification list via CignaforHCP. EN0499 (read in full 9/17/2026) sets medical-necessity criteria but states no prior-authorization requirement for any ABA code, so the PA answer cannot be sourced to it. [1]
- **Prior auth for treatment:** Not published / unverified. Verify via: Cigna/Evernorth's precertification list via CignaforHCP. EN0499 (read in full 9/17/2026) sets medical-necessity criteria but states no prior-authorization requirement for any ABA code, so the PA answer cannot be sourced to it. [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:** Utah Code § 31A-22-642
- **Mandate markets:** Individual + large group only — small group NOT covered
- **Mandate age:** No age limit (plans entered/renewed on or after 1/1/2020)
- **Mandate caps:** No hour limit since 2020; 600 hr/yr floor on legacy pre-2020 plans
- **Exempt from mandate:** Small group plans; self-funded ERISA
- **Licensure:** UT Licensed Behavior Analyst (DOPL, Utah Code 58-61 Part 7)

## The national policy, applied in Utah

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 Virginia — the one state EN0499 carves out — Utah fully-insured business is squarely subject to the policy, so the no-assessment-PA fast path holds here, with the Utah mandate controlling wherever it is more generous. Plan market segment and funding type are still the first facts to establish on every benefits check. The full national policy breakdown lives in our Cigna / Evernorth guide; this page covers what changes in Utah. [1][2]

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

Utah Code § 31A-22-642 requires coverage for the diagnosis and treatment of autism spectrum disorder in the individual and large-group markets — small group plans are not named by the statute, making market segment the load-bearing question in Utah, even ahead of funding type. For plans entered or renewed on or after January 1, 2020 there is no age limit and no cap on covered ABA hours; the older 600-hours-a-year floor and the ages-2-to-under-10 window govern only legacy pre-2020 plans. The statute has operational teeth, too: the treatment plan is due to the insurer within 14 business days of starting treatment, the insurer may review it at most once every 3 months, and plan networks must include both board certified behavior analysts and qualified licensed mental health providers. Its diagnosis definition is strict — a board-certified neurologist, psychiatrist, or pediatrician with ASD experience, or an experienced licensed psychologist. Self-funded ERISA plans are exempt by federal preemption, and MHPAEA supplies the parity floor for group plans. New from the 2026 amendment: beginning before July 1, 2027, every health benefit plan must report autism-assessment wait times, whether it imposes PA on assessment or treatment, and ABA utilization to the Utah Insurance Department annually — with public website disclosure of which plans reimburse non-physician therapists from September 1, 2027. Insurer PA behavior in Utah is about to become public record. [3][5]

## No Utah-specific Cigna policy exists

We checked: Cigna / Evernorth publishes no Utah-specific ABA policy, form, or supplement — EN0499 mentions Utah nowhere, and its only state exclusion is Virginia. The national policy plus the state mandate is the whole picture. That's worth knowing in itself: it means benefits verification (market segment, plan funding type, mandate applicability) is where Utah-specific answers come from, not a carrier document. Cigna also holds no Utah Medicaid ACO contract, so there is no Medicaid line of business to confuse a Cigna card with here. [1]

## Licensure & rates in Utah

Utah requires a license to practice behavior analysis: the Licensed Behavior Analyst (LBA) and Licensed Assistant Behavior Analyst (LABA) credentials under the Behavior Analyst Licensing Act (Utah Code Title 58, Chapter 61, Part 7), administered by the Division of Professional Licensing (DOPL). Behavior technicians work as certified paraprofessionals under QHP supervision rather than as licensees. On rates: Cigna does not publish commercial ABA fee schedules for Utah (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement. Utah does give you a public benchmark, though: the Medicaid PRISM rates effective 7/1/2026 pay $19.67 per 15-minute unit on 97153 and $37.51 on 97151/97155/97156. [4]

## Intake gates

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

- **Age limit**: EN0499 sets no age limit — its gate is a confirmed ASD diagnosis. Utah fully-insured business is squarely subject to EN0499 (Virginia is the policy's only state carve-out). In Utah the legal floor is Utah Code § 31A-22-642: no age limit and no cap on covered ABA hours for individual and large-group plans entered or renewed on or after 1/1/2020 (the 600-hours-a-year floor and the ages-2-to-under-10 window govern only legacy pre-2020 plans), the treatment plan due to the insurer within 14 business days of starting treatment, and insurer review at most once every 3 months. Small-group plans are not named by the statute and self-funded ERISA plans are exempt, so market segment is the load-bearing question. [1][3]
- **Diagnosis recency**: EN0499 sets no recency window on the ASD diagnosis itself, but requires the date on which the diagnosis was most recently made to be supplied, and requires the standardized ABA assessment instrument to have been administered within the 60 days before treatment starts. [1]
- **Who may diagnose**: A confirmed ASD diagnosis (ICD-10-CM F84.0-F84.9, excluding F84.2 Rett syndrome) made against DSM-5-TR criteria by a health care professional licensed to practise independently and whose licensure board considers diagnostics within their scope of practice, with the name, credentials and type of licensure of the diagnosing clinician provided. The Utah mandate's own diagnosis definition is strict and applies to plans it reaches: a board-certified neurologist, psychiatrist or pediatrician with ASD experience, or an experienced licensed psychologist. [1][3]
- **Diagnostic tools required**: A reliable, valid and standardized assessment instrument measuring the DSM-5-TR ASD domains. EN0499 names no fixed list but sets conditions: completed in its entirety and as designed, reliability and validity established for the population tested, administered and interpreted by someone trained to do so, the most current version (Vineland-3, not Vineland-II), and reported with the date of administration, the respondent, and the form type. [1]
- **Referral required?**: EN0499 imposes no referral or physician order — the gate is the confirmed independent-licensure diagnosis plus a full ABA assessment by a BCBA, LBA, or independently licensed mental health clinician with documented ABA training, and where that assessment came from someone other than the requesting provider, documented collaboration plus confirmation that the results reflect current functioning. The Utah mandate adds its own clock: the treatment plan is due to the insurer within 14 business days of starting treatment. [1][3]
- **Telehealth**: EN0499 treats ABA as deliverable in person, by telehealth, or as a hybrid, with the modality chosen on individual characteristics, the treatment plan, caregiver participation, environment, evidence of efficacy and safety, and technological requirements; the line-of-sight and close-proximity requirement on direct treatment expressly does not apply to telehealth services. [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. Utah requires fully insured plans' procedures to "comply with this rule, 29 CFR 2560.503-1, and 45 CFR 147.136" (R590-261-4), and self-funded plans follow 29 CFR 2560.503-1 directly, so through 2026 the ceiling is the same either way: a pre-service decision "not later than 15 days after receipt of the claim" (one 15-day extension) and 72 hours for urgent care. From January 1, 2027 Utah Code 31A-22-650 tightens insurers (fully insured only) to "no later than seven calendar days after the day on which the insurer receives all necessary information," and 72 hours for urgent care. [6][2][7][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. Utah's COB rule (R590-131-6) 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); a court order stating otherwise 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)). [6][10][11][12][13]

## Delivery and billing rules

Coverage decides whether Cigna / Evernorth in Utah 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, LBA, or a mental health professional licensed to practise independently with documented ABA training. Direct case supervision (the BCBA face-to-face with the individual and the RBT or BCaBA delivering treatment) plus indirect case supervision runs at the accepted standard of one to two hours per ten hours of direct treatment; where direct treatment is 10 hours a week or less, a minimum of one to two hours a week of direct case supervision is provided, and the name and credentials of the supervisor must be documented. In Utah the LBA must additionally hold a DOPL licence under Utah Code 58-61 Part 7. [1][4]
- **Concurrent billing (97153 + 97155)**: EN0499 defines concurrent billing as multiple providers billing for the same patient at the same time regardless of funding source, and flatly excludes ABA delivered to the same individual at the same time as any other treatment modality (ABA and speech therapy, or ABA and occupational therapy). ABA delivered by multiple provider organizations in the same authorization period is not medically necessary unless additional documented conditions are met. It does not separately bless or bar a 97153-plus-97155 pairing. [1]
- **Daily limits / MUEs**: No per-day or per-week unit ceiling is published. EN0499 defines treatment intensity as direct ABA treatment hours per week, excluding case supervision and caregiver training, individually determined from assessment data and set on medical necessity independent of the individual's outside schedule or prior utilization. Under the Utah mandate there is no hour cap for individual and large-group plans entered or renewed since 1/1/2020. [1][3]
- **Session-note signature**: Each session record must carry the start date and time, end date and time, location of service delivery, focus of service, a detailed description of the intervention, 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**: Goals must be defined across every setting where treatment will occur, and EN0499 names residential facilities, childcare facilities, homes, schools, transportation, community settings, clinics, vocational or educational classes, and recreational and social environments as payable sites when medically necessary. The boundary is purpose: services primarily educational or vocational in nature, or related to academic or work performance, are not covered, and ABA may not replace or replicate activities that are the responsibility of the setting — classroom aide, 1:1 teacher, tutor, vocational coach, respite. [1]
- **Bill as provider** _(plan-dependent)_: EN0499 governs who may render and supervise but publishes no rendering-versus-supervising NPI rule; claim-level attribution is a reimbursement-policy and contract question. In Utah, whoever supervises must hold the DOPL behavior-analyst licence. [1][4]
  - Ask the plan: Cigna/Evernorth provider services and the participating-provider agreement — EN0499 is a coverage policy and carries no claim-attribution rule.

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

- **Market segment + funding type:** Individual or large group fully-insured (mandate applies) vs. small group or self-funded ERISA (exempt) — in Utah this decides everything. 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 + diagnosing provider credentials:** The mandate's diagnosis definition names specific credentials (neurologist, psychiatrist, pediatrician with ASD experience, or licensed psychologist) — capture who diagnosed.
- **Treatment start date:** The mandate's treatment plan is due to the insurer within 14 business days of starting treatment — put the clock on the calendar.

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

## Verification of benefits (VOB) data

How Cigna / Evernorth in Utah 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, 0362T:** Verify via: Cigna/Evernorth provider services — EN0499 is a medical-necessity policy only; no coding/reimbursement mechanics are published in it. Utah is fully subject to EN0499 (only Virginia is carved out), so the no-assessment-PA fast path holds. QA verify (2026-07-23): EN0499 as fetched publishes only medical-necessity criteria and contains no 'prior authorization'/'precertification' language and no statement exempting assessment codes from PA, so this 'Not required' value is downgraded from verified to unverified pending confirmation via Cigna/Evernorth precertification lists.
- **97153, 97154, 97155, 97156, 97157, 97158, 0373T:** Verify via: Cigna/Evernorth provider services — EN0499 is a medical-necessity policy only; no coding/reimbursement mechanics are published in it. Utah is fully subject to EN0499 (only Virginia is carved out), so the no-assessment-PA fast path holds.

### Contacts

- **Provider services phone:** 1 (800) 926-2273 (Evernorth Behavioral Health Provider Advocate team / National Care Center)
- **Portal:** [CignaforHCP](https://cignaforhcp.cigna.com/app/login)

Questions to ask on a verification call:

- Are there unit or hour caps on the treatment codes (97153-97158), and if so what are they?
- What place-of-service settings are allowed for ABA — home, clinic, school, telehealth?
- Is telehealth allowed for any of the ABA codes, and if so which ones?
- Are licensure-tier modifiers required on claims, and if so which apply to which codes?

### 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://static.evernorth.com/assets/evernorth/provider/resourceLibrary/behavioralResources/doingBusinessWithUs/cbhProviderServiceCenter.html (accessed 2026-07-23)
- https://www.cigna.com/health-care-providers/coverage-and-claims/precertification (accessed 2026-07-23)
- https://www.cigna.com/health-care-providers/cigna-for-hcp-online-portal-features (accessed 2026-07-23)

## Common questions

### Does Cigna cover ABA therapy in Utah?

Yes — under national policy EN0499 (which fully applies in Utah, unlike Virginia), layered on Utah's mandate (Utah Code § 31A-22-642) for individual and large-group fully-insured plans. Small-group and self-funded employer plans sit outside the mandate, so always verify market segment and funding type first.

### Does the ABA assessment need prior authorization with Cigna in Utah?

No — EN0499 requires no PA on assessment codes 97151, 97152, and 0362T, and Utah is fully subject to that policy. Treatment then requires the completed assessment plus a treatment plan with Cigna's ABA PA form.

### What does the Utah autism mandate require?

For individual and large-group plans entered or renewed since 1/1/2020: coverage for ASD diagnosis and treatment with no age limit and no cap on ABA hours, a treatment plan due within 14 business days of starting treatment, insurer reviews at most every 3 months, and networks that include BCBAs. Small group is not covered by the statute.

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

Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against Utah Medicaid's published PRISM rates ($19.67/unit on 97153, $37.51 on 97151/97155/97156, effective 7/1/2026) 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](https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/autism-resource-guide.pdf)
3. [Utah Code § 31A-22-642 (current, eff. 5/6/2026)](https://le.utah.gov/xcode/Title31A/Chapter22/C31A-22-S642_2026050620260506.pdf)
4. [Behavior Analyst Licensing Act — Utah Code 58-61 Part 7](https://le.utah.gov/xcode/Title58/Chapter61/C58-61-P7_2015051220150701.pdf)
5. [Utah Code § 31A-22-642 (prior version, effective 5/4/2022)](https://le.utah.gov/xcode/Title31A/Chapter22/C31A-22-S642_2022050420220504.pdf)
6. [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)
7. [Utah Admin. Code R590-261-4 — Adverse Benefit Determination Procedure Compliance (Cornell LII mirror; rules.utah.gov blocked)](https://www.law.cornell.edu/regulations/utah/Utah-Admin-Code-R590-261-4)
8. [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)
9. [Utah Code 31A-22-650 — Health care preauthorization requirements (version effective 1/1/2027, SB 319 of 2026)](https://le.utah.gov/xcode/Title31A/Chapter22/C31A-22-S650_2026050620270101.html)
10. [Utah Admin. Code R590-131-6 — Determining Order of Benefits (Cornell LII mirror)](https://www.law.cornell.edu/regulations/utah/Utah-Admin-Code-R590-131-6)
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.