---
title: "Cigna / Evernorth ABA coverage in Virginia: the intake guide."
url: "https://carelu.com/payers/cigna-virginia"
markdown_url: "https://carelu.com/payers/cigna-virginia.md"
state: VA (Virginia)
payer: Cigna / Evernorth in Virginia
kind: Commercial insurance
description: "How Cigna / Evernorth covers ABA for Virginia families — the national clinical policy, prior authorization, the Va. Code § 38.2-3418.17 mandate (ages, caps, exemptions), Virginia behavior-analyst licensure, and what intake should verify."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

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

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

> EN0499 + autism resource guide + the Va. Code § 38.2-3418.17 mandate layer.

For an intake team in Virginia, a Cigna card means three layers at once: the carrier's national clinical policy, Virginia's autism insurance mandate (Va. Code § 38.2-3418.17), and the plan's funding type deciding which of the two actually binds. This guide stacks them in order. One Virginia-sized caveat up front: Cigna’s national EN0499 policy explicitly does not apply to Virginia fully-insured business, so the usual no-assessment-PA fast path can’t be assumed until you know the plan’s funding type.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment** _(plan-dependent)_: Depends on funding type — EN0499's no-PA-on-97151/97152/0362T fast path reaches self-funded (ASO) plans only; Virginia fully-insured business is carved out of EN0499, so the plan document and the state mandate govern [1]
  - Ask the plan: A live benefits verification of funding type. EN0499 states verbatim that “Virginia fully insured business is not subject to this coverage policy,” so for a fully-insured member the plan document and the mandate govern. Note also that EN0499 (read in full 9/17/2026) states no prior-authorization requirement for any ABA code — the no-PA-on-assessment fast path comes from Cigna's precertification list, not from EN0499.
- **Prior auth for treatment** _(plan-dependent)_: Required — for self-funded plans, the completed assessment plus a treatment plan on Cigna's ABA PA form (see Cigna's autism resource guide; EN0499 sets the clinical criteria, not the PA rule); for fully-insured Virginia plans confirm the authorization requirement against the plan document [1]
  - Ask the plan: A live benefits verification of funding type. EN0499 states verbatim that “Virginia fully insured business is not subject to this coverage policy,” so for a fully-insured member the plan document and the mandate govern. Note also that EN0499 (read in full 9/17/2026) states no prior-authorization requirement for any ABA code — the no-PA-on-assessment fast path comes from Cigna's precertification list, not from EN0499.
- **Autism diagnosis required?**: Yes — ASD only; Rett syndrome (F84.2) excluded under EN0499. Virginia separately requires the prescribing practitioner to be a licensed physician or psychologist independent of the ABA provider [1][3]

## At a glance

- **Covers ABA?:** Yes — for ASD, per the national Cigna policy
- **State mandate:** Va. Code § 38.2-3418.17
- **Mandate age:** Any age (since 1/1/2020, HB 2577)
- **Mandate caps:** $35,000/yr ABA cap in statute (parity-limited)
- **Exempt from mandate:** Short-term/limited policies; self-funded ERISA
- **Licensure:** VA Licensed Behavior Analyst (Board of Medicine)

## The national policy, applied in Virginia

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 Virginia 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 Virginia. [1][2]

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

Virginia’s mandate covers individual and group policies and HMO plans, and since January 1, 2020 it applies at any age — the old age caps were removed by 2019’s HB 2577. ABA is subject to an annual maximum benefit of $35,000 unless the insurer elects more (still in the current statute), must be provided or supervised by a behavior analyst licensed by the Board of Medicine, and the prescriber must be independent of the ABA provider. Self-funded ERISA plans are exempt by preemption, and the $35K cap is a quantitative limit of doubtful MHPAEA enforceability for large-group plans. [3][4]

## The Virginia carve-out: EN0499 does not apply to fully-insured plans

The current EN0499 states verbatim that Virginia fully-insured business is not subject to the policy. For fully-insured Cigna members in Virginia, coverage terms come from the plan document and the state mandate — not Cigna’s national IBI criteria — while self-funded (ASO) plans still follow EN0499. Practically: for a Virginia Cigna family, don’t assume the no-assessment-PA fast path or any other EN0499 rule until benefits verification confirms which regime the plan sits under. [1]

## Licensure & rates in Virginia

Virginia requires a Board of Medicine license to practice as a behavior analyst (Va. Code § 54.1-2957.16, built on BACB certification) — and the mandate itself conditions ABA coverage on delivery or supervision by a licensed behavior analyst, so licensure is a coverage requirement, not just a credentialing one. On rates: Cigna does not publish commercial ABA fee schedules for Virginia (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. [5]

## Intake gates

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

- **Who may diagnose**: Virginia is the one state EN0499 carves out — the policy states that Virginia fully-insured business is not subject to it. For a fully-insured Virginia member the plan document and the state mandate govern; for self-funded (ASO) plans EN0499 still applies, so funding type decides which rulebook you are reading. Under EN0499: a confirmed ASD diagnosis (F84.0-F84.9, excluding F84.2 Rett syndrome) against DSM-5-TR criteria by a health care professional licensed to practise independently whose licensure board considers diagnostics within scope, with the name, credentials and licensure type of the diagnosing clinician provided. Under the Virginia mandate the standard is narrower. Virginia writes the gate into the benefit itself: covered ABA must be provided or supervised by a board certified behavior analyst licensed by the Board of Medicine, and the prescribing practitioner must be independent of the ABA provider. The treatment plan is defined as one developed by a licensed physician or licensed psychologist following a comprehensive evaluation or reevaluation performed consistently with the most recent clinical report or recommendation of the AAP or AACAP, and treatment must be prescribed or ordered by a licensed physician or psychologist who determines it medically necessary. A referral written by a clinician inside your own practice can fail the independence test. [1][3][5]
- **Diagnostic tools required**: Virginia is the one state EN0499 carves out — the policy states that Virginia fully-insured business is not subject to it. For a fully-insured Virginia member the plan document and the state mandate govern; for self-funded (ASO) plans EN0499 still applies, so funding type decides which rulebook you are reading. EN0499 requires a reliable, valid and standardized assessment instrument measuring the DSM-5-TR ASD domains, completed in its entirety and as designed, with reliability and validity established for the population tested, administered and interpreted by someone trained to do so, in the most current version (Vineland-3, not Vineland-II), reported with the date of administration, the respondent and the form type. The Virginia statute names no instrument but requires the comprehensive evaluation behind the treatment plan to follow the most recent AAP or AACAP clinical report or recommendation. [1][3]
- **Referral required?**: Yes, and it is statutory rather than a carrier rule: treatment must be prescribed or ordered by a licensed physician or licensed psychologist who determines the care medically necessary, and that prescribing practitioner must be independent of the ABA provider. The insurer may review the treatment plan not more than once every 12 months unless the insurer and the individual's licensed physician or psychologist agree more frequent review is necessary, with the cost of any such review covered under the policy. EN0499 itself imposes no referral requirement — for self-funded plans the gate is the independent-licensure diagnosis plus a full ABA assessment by a BCBA, LBA, or independently licensed mental health clinician with documented ABA training. [3][1]
- **Age limit** _(plan-dependent)_: Virginia is the one state EN0499 carves out — the policy states that Virginia fully-insured business is not subject to it. For a fully-insured Virginia member the plan document and the state mandate govern; for self-funded (ASO) plans EN0499 still applies, so funding type decides which rulebook you are reading. Under EN0499 there is no age limit — the gate is a confirmed ASD diagnosis. Any age. Virginia's mandate has applied to individuals of any age since 1/1/2020 — 2019's HB 2577 removed the old age-2 floor as well as the upper limit — for individual and group policies and HMO contracts, extended to the individual and small group markets for policies delivered, issued, reissued or extended on or after 1/1/2021. ABA remains subject to a $35,000 annual maximum benefit unless the insurer elects more, with no visit limits; as a quantitative treatment limit on a mental-health benefit that cap is a live parity question for large-group plans rather than a settled rule. Self-funded ERISA plans sit outside the statute. [1][3]
  - Ask the plan: A live benefits verification — fully-insured Virginia business is outside EN0499, so the plan document and the mandate control.
- **Diagnosis recency** _(plan-dependent)_: Virginia is the one state EN0499 carves out — the policy states that Virginia fully-insured business is not subject to it. For a fully-insured Virginia member the plan document and the state mandate govern; for self-funded (ASO) plans EN0499 still applies, so funding type decides which rulebook you are reading. EN0499 sets no recency window on the ASD diagnosis itself, but requires the date the diagnosis was most recently made to be supplied and the standardized ABA assessment instrument to have been administered within the 60 days before treatment starts. The Virginia mandate sets no recency rule but caps insurer-initiated treatment-plan review at once every 12 months. [1][3]
  - Ask the plan: A live benefits verification — the 60-day assessment-currency rule binds only self-funded plans reading EN0499.
- **Telehealth** _(plan-dependent)_: Virginia is the one state EN0499 carves out — the policy states that Virginia fully-insured business is not subject to it. For a fully-insured Virginia member the plan document and the state mandate govern; for self-funded (ASO) plans EN0499 still applies, so funding type decides which rulebook you are reading. EN0499 treats ABA as deliverable in person, by telehealth, or as a hybrid, with the line-of-sight and close-proximity requirement on direct treatment expressly not applying to telehealth. The Virginia mandate is silent on modality. [1][3]
  - Ask the plan: A live benefits verification — for fully-insured Virginia members the plan document, not EN0499, sets modality terms.
- **Prior-auth decision time** _(plan-dependent)_: Depends on how the plan is funded. Fully insured Virginia plans: Virginia's utilization-review statute requires the entity to "communicate its utilization review decision no later than two business days after receipt by the entity of all information necessary to complete the review" — the clock starts only once the file is complete. Self-funded (ERISA) plans are excluded from that article and follow the federal claims rule instead: a pre-service decision within 15 days of receipt (one 15-day extension allowed, with notice; if the extension is for missing information you get at least 45 days to supply it) and an urgent-care decision within 72 hours; a request to extend an ongoing course of treatment that is urgent is decided within 24 hours if made at least 24 hours before the current authorization expires. Cigna's ABA policy (EN0499) publishes no decision clock; what it dates is the reauthorization packet — continued-treatment requests need current data "collected within no more than 60 days prior to the start date of the continued treatment request," so collect progress data inside that window. [6][7][8][1]
  - Ask the plan: Benefits verification: ask whether the plan is fully insured (Virginia UR statute applies) or self-funded ERISA (federal 15-day/72-hour rule), and the carrier's turnaround for its behavioral health reviewer.
- **Other insurance (who pays first)** _(plan-dependent)_: Cigna's ABA documents publish no coordination-of-benefits rule; order of benefits follows the plan document. If the child also has TRICARE, this plan pays first — TRICARE is the secondary payer to other health insurance under its double-coverage rule (Medicaid is the only coverage it pays ahead of). CHAMPVA likewise pays last: "In double coverage situations, CHAMPVA would be the last payer." If the child also has Medicaid, this plan is primary and Medicaid pays last. When the child has two parents' plans, the plan's own coordination-of-benefits provision decides the order — a self-funded plan writes its own rules. For Virginia HMO contracts, 14VAC5-211-80 lets the plan coordinate but says it "shall not be relieved of its duty to provide a covered health care service" because of other coverage, must "provide or arrange for the service first and then, at its option, seek coordination of benefits," and "Until a coordination of benefits determination is made, the enrollee shall not be held liable." [9][10][11][12]
  - Ask the plan: Benefits verification with each plan: which is primary for the child (order-of-benefits rule, custody/court order), and whether the secondary plan needs its own authorization.

## Delivery and billing rules

Coverage decides whether Cigna / Evernorth in Virginia 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**: Under EN0499 (self-funded plans): case supervision by a BCBA, LBA, or independently licensed mental health professional with documented ABA training, with direct plus indirect case supervision at one to two hours per ten hours of direct treatment, and a minimum of one to two hours a week of direct case supervision where direct treatment is 10 hours a week or less. In Virginia the mandate adds a coverage condition regardless of funding: covered ABA must be provided or supervised by a board certified behavior analyst licensed by the Board of Medicine. [1][3][5]
- **Bill as provider**: EN0499 governs who may render and supervise but publishes no rendering-versus-supervising NPI rule. In Virginia the mandate does constrain the claim: covered ABA must be provided or supervised by a board certified behavior analyst licensed by the Board of Medicine, and the prescribing practitioner must be independent of the ABA provider. [3][5][1]
- **Concurrent billing (97153 + 97155)** _(plan-dependent)_: 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. For fully-insured Virginia members that policy does not apply, so claim editing follows the plan document. [1]
  - Ask the plan: A live benefits verification — Virginia fully-insured business is carved out of EN0499, so concurrent-billing edits come from the plan document and Cigna reimbursement policy.
- **Daily limits / MUEs** _(plan-dependent)_: 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, set on medical necessity independent of the individual's outside schedule or prior utilization. Virginia bars visit limits outright but keeps a $35,000 annual maximum benefit on ABA unless the insurer elects more — a quantitative treatment limit whose enforceability against a large-group plan is a parity question. [1][3]
  - Ask the plan: A live benefits verification — whether the plan applies the $35,000 maximum, and any plan-level limits.
- **Session-note signature** _(plan-dependent)_: Under EN0499 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, and the name, credential where applicable, and signature of the ABA provider who rendered the service. For fully-insured Virginia members that policy does not bind; the plan document does. [1]
  - Ask the plan: A live benefits verification — Virginia fully-insured business is carved out of EN0499.
- **Place of service** _(plan-dependent)_: Under EN0499, ABA may be delivered in residential facilities, childcare facilities, homes, schools, transportation, community settings, clinics, vocational or educational classes, and recreational and social environments when medically necessary — but 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). For fully-insured Virginia members the plan document governs instead. [1]
  - Ask the plan: A live benefits verification — Virginia fully-insured business is carved out of EN0499.

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

- **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 Virginia ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00004 — pVerify 00004 = "Cigna" (Medical, Eligibility=Yes); pVerify also lists "Cigna Behavioral" 00510.
- **Payer ID (Availity):** 62308 — Evernorth payer ID 62308 per the Cigna Autism Resource Guide (same ID as Cigna medical — no separate Evernorth EDI hop); inferred pending a current Availity export.
- **Payer ID (Change Healthcare / Optum):** 62308 — Change Healthcare/Optum professional-claims list confirms 62308 = "CIGNA - PPO" (supports 270/271).
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** Evernorth Behavioral Health (same-payer-ID pass-through)
- **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 | Plan-dependent — for fully-insured VA members, coverage comes from the plan document + the Va. Code § 38.2-3418.17 mandate, NOT EN0499; self-funded (ASO) plans follow EN0499. | No PA panel published for this guide — EN0499 explicitly does not apply to Virginia fully-insured business, so the national no-assessment-PA / treatment-PA rules cannot be assumed. Determine the plan's funding type on a live benefits check before assuming any PA verdict. | plan-dependent per plan-dependent | plan-dependent | plan-dependent | plan-dependent |
| 97152 | Plan-dependent — for fully-insured VA members, coverage comes from the plan document + the Va. Code § 38.2-3418.17 mandate, NOT EN0499; self-funded (ASO) plans follow EN0499. | No PA panel published for this guide — EN0499 explicitly does not apply to Virginia fully-insured business, so the national no-assessment-PA / treatment-PA rules cannot be assumed. Determine the plan's funding type on a live benefits check before assuming any PA verdict. | plan-dependent per plan-dependent | plan-dependent | plan-dependent | plan-dependent |
| 97153 | Plan-dependent — for fully-insured VA members, coverage comes from the plan document + the Va. Code § 38.2-3418.17 mandate, NOT EN0499; self-funded (ASO) plans follow EN0499. | No PA panel published for this guide — EN0499 explicitly does not apply to Virginia fully-insured business, so the national no-assessment-PA / treatment-PA rules cannot be assumed. Determine the plan's funding type on a live benefits check before assuming any PA verdict. | plan-dependent per plan-dependent | plan-dependent | plan-dependent | plan-dependent |
| 97154 | Plan-dependent — for fully-insured VA members, coverage comes from the plan document + the Va. Code § 38.2-3418.17 mandate, NOT EN0499; self-funded (ASO) plans follow EN0499. | No PA panel published for this guide — EN0499 explicitly does not apply to Virginia fully-insured business, so the national no-assessment-PA / treatment-PA rules cannot be assumed. Determine the plan's funding type on a live benefits check before assuming any PA verdict. | plan-dependent per plan-dependent | plan-dependent | plan-dependent | plan-dependent |
| 97155 | Plan-dependent — for fully-insured VA members, coverage comes from the plan document + the Va. Code § 38.2-3418.17 mandate, NOT EN0499; self-funded (ASO) plans follow EN0499. | No PA panel published for this guide — EN0499 explicitly does not apply to Virginia fully-insured business, so the national no-assessment-PA / treatment-PA rules cannot be assumed. Determine the plan's funding type on a live benefits check before assuming any PA verdict. | plan-dependent per plan-dependent | plan-dependent | plan-dependent | plan-dependent |
| 97156 | Plan-dependent — for fully-insured VA members, coverage comes from the plan document + the Va. Code § 38.2-3418.17 mandate, NOT EN0499; self-funded (ASO) plans follow EN0499. | No PA panel published for this guide — EN0499 explicitly does not apply to Virginia fully-insured business, so the national no-assessment-PA / treatment-PA rules cannot be assumed. Determine the plan's funding type on a live benefits check before assuming any PA verdict. | plan-dependent per plan-dependent | plan-dependent | plan-dependent | plan-dependent |
| 97157 | Plan-dependent — for fully-insured VA members, coverage comes from the plan document + the Va. Code § 38.2-3418.17 mandate, NOT EN0499; self-funded (ASO) plans follow EN0499. | No PA panel published for this guide — EN0499 explicitly does not apply to Virginia fully-insured business, so the national no-assessment-PA / treatment-PA rules cannot be assumed. Determine the plan's funding type on a live benefits check before assuming any PA verdict. | plan-dependent per plan-dependent | plan-dependent | plan-dependent | plan-dependent |
| 97158 | Plan-dependent — for fully-insured VA members, coverage comes from the plan document + the Va. Code § 38.2-3418.17 mandate, NOT EN0499; self-funded (ASO) plans follow EN0499. | No PA panel published for this guide — EN0499 explicitly does not apply to Virginia fully-insured business, so the national no-assessment-PA / treatment-PA rules cannot be assumed. Determine the plan's funding type on a live benefits check before assuming any PA verdict. | plan-dependent per plan-dependent | plan-dependent | plan-dependent | plan-dependent |
| 0362T | Plan-dependent — for fully-insured VA members, coverage comes from the plan document + the Va. Code § 38.2-3418.17 mandate, NOT EN0499; self-funded (ASO) plans follow EN0499. | No PA panel published for this guide — EN0499 explicitly does not apply to Virginia fully-insured business, so the national no-assessment-PA / treatment-PA rules cannot be assumed. Determine the plan's funding type on a live benefits check before assuming any PA verdict. | plan-dependent per plan-dependent | plan-dependent | plan-dependent | plan-dependent |
| 0373T | Plan-dependent — for fully-insured VA members, coverage comes from the plan document + the Va. Code § 38.2-3418.17 mandate, NOT EN0499; self-funded (ASO) plans follow EN0499. | No PA panel published for this guide — EN0499 explicitly does not apply to Virginia fully-insured business, so the national no-assessment-PA / treatment-PA rules cannot be assumed. Determine the plan's funding type on a live benefits check before assuming any PA verdict. | plan-dependent per plan-dependent | plan-dependent | plan-dependent | plan-dependent |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** Intentionally no invented PA fields: the current EN0499 (eff. 5/15/2026) states verbatim that Virginia fully-insured business is not subject to the policy. Verify via: a live benefits check (funding type first) + Cigna/Evernorth provider services; for fully-insured plans, the plan document and the state mandate govern.

### Contacts

- **Provider services phone:** 1-800-926-2273 — Evernorth/Cigna Behavioral Health provider services (general Cigna provider line: 1-800-88CIGNA / 882-4462)
- **Portal:** [CignaforHCP](https://cignaforhcp.cigna.com/app/login)

Questions to ask on a verification call:

- Is this member's Cigna plan fully insured or self-funded (ASO)? Fully-insured Virginia plans aren't subject to EN0499 — coverage runs off the plan document and the state mandate instead.
- Since there's no published PA panel for this plan type, is prior authorization required for ABA, and through what process?
- What unit caps or session limits apply to 97153 and the other treatment codes under this plan?
- Which places of service and telehealth modifiers are covered?
- Are licensure-tier billing requirements (BCBA/RBT) in place under this plan?

### VOB data sources

- https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/autism-resource-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://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://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://www.cigna.com/health-care-providers/credentialing (accessed 2026-07-23)

## Common questions

### Does Cigna cover ABA therapy in Virginia?

Yes — under the carrier's national policy for ASD, layered on Virginia's mandate (Va. Code § 38.2-3418.17) for fully-insured plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first.

### What does the Virginia autism mandate require?

Virginia’s mandate covers individual and group policies and HMO plans, and since January 1, 2020 it applies at any age — the old age caps were removed by 2019’s HB 2577. 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 Virginia?

Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against the Virginia 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. [Va. Code § 38.2-3418.17 (official — Virginia LIS)](https://law.lis.virginia.gov/vacode/title38.2/chapter34/section38.2-3418.17/)
4. [Autism Speaks — Virginia state-regulated coverage](https://www.autismspeaks.org/virginia-state-regulated-insurance-coverage)
5. [Va. Code § 54.1-2957.16 — behavior analyst licensure (official)](https://law.lis.virginia.gov/vacode/title54.1/chapter29/section54.1-2957.16/)
6. [Va. Code § 32.1-137.9 — utilization review standards (Virginia LIS)](https://law.lis.virginia.gov/vacode/title32.1/chapter5/section32.1-137.9/)
7. [Va. Code § 32.1-137.8 — application; ERISA-exempt plans excluded (Virginia LIS)](https://law.lis.virginia.gov/vacode/title32.1/chapter5/section32.1-137.8/)
8. [29 CFR 2560.503-1 — ERISA claims procedure (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
9. [14VAC5-211-80 — HMO coordination of benefits (Virginia LIS)](https://law.lis.virginia.gov/admincode/title14/agency5/chapter211/section80/)
10. [32 CFR 199.8 — TRICARE double coverage (eCFR)](https://www.ecfr.gov/current/title-32/section-199.8)
11. [38 CFR 17.270 — CHAMPVA definitions, double coverage (eCFR)](https://www.ecfr.gov/current/title-38/section-17.270)
12. [42 CFR 433.139 — Medicaid third-party liability, payment of claims (eCFR)](https://www.ecfr.gov/current/title-42/section-433.139)

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.