CurrentCignaPolicy N/A

Tennessee ABA Prior Authorization Form

A Tennessee-specific prior authorization form and instructions for Applied Behavior Analysis (ABA) treatment requests to Evernorth/Cigna; includes provider registration, form completion tips, required clinical information, and contact/submission methods. Governs how providers submit ABA authorization requests for Tennessee members.

Policy Summary

PayerCigna

PolicyTennessee ABA Prior Authorization Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit a completed Tennessee ABA Prior Authorization Form with required clinical details and CPT codes/units to Evernorth via the online tool (after registration), fax (860.687.9230), or email (ABA@Evernorth.com) to request authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — form and instructions remain informational and administrative.

1Form document

TennesseeState-specific

Policy overview

Payer: Cigna; Policy: Tennessee ABA Prior Authorization Form; Policy Number: N/A; Effective Date:

Scope: A Tennessee-specific prior authorization form and instructions for Applied Behavior Analysis (ABA) treatment requests to Evernorth/Cigna; includes provider registration, form completion tips, required clinical information, and contact/submission methods. Governs how providers submit ABA authorization requests for Tennessee members.

Background: This form is intended to be completed by a provider knowledgeable about the patient's ABA clinical presentation and treatment history and is based on Evernorth Medical Necessity Criteria for ABA. The form is provided to replace telephonic clinical review if fully completed and may be used in lieu of a phone review to expedite authorization. Providers in Tennessee must register for access to the online prior authorization tool (email PMAC@Cigna.com) and may also submit via fax to 860.687.9230 or email to ABA@Evernorth.com.

Form completion and required information

To help expedite review, the form must be fully completed and include the specific items listed below. Omissions or generalities may result in return for additional information.

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Documentation Required

Documentation required

The individualized treatment plan must be submitted (or attached) and include specific, measurable goals, baseline and current data for each goal, parent/caregiver training objectives with progress data, and clear discharge/transition criteria. Assessment scores (current, previous, and baseline) with dates must be included for any standardized measures reported. If attachments are provided, list the documents and page counts. Incomplete treatment plans or missing assessment scores may result in the request being returned for additional information.

Attach current individualized treatment plan and/or progress report (include page count).
Include assessment score tables showing baseline, previous/interim, and current scores with dates for each instrument.
Requests lacking a detailed treatment plan or required assessment scores may be returned for clarification or additional documentation.

Billing Rule

CPT code submission requirements

Providers must list all requested CPT codes and indicate units for the authorization period or, where requested, units per month. Include codes for reassessment, supervision, parent/caregiver training, and direct treatment.

List CPT code(s) for reassessment and specify units requested per authorization period.
List CPT code(s) for supervision and indicate units per month.
List CPT code(s) for parent/caregiver training and indicate units per month.
List CPT code(s) for direct treatment and indicate units per month.

How to submit the form

Prior Authorization

Prior authorization submission required for ABA services

Submit a completed Tennessee ABA Prior Authorization Form including required clinical details and the requested CPT codes/units to Evernorth to request authorization. Tennessee providers may file electronically (after registering), or send the form via fax or email.

Fax: 860.687.9230
Email: ABA@Evernorth.com
Tennessee provider registration email for online tool access: PMAC@Cigna.com

Definitions

Defined termEvernorth Behavioral Health, Inc. and subsidiaries including Evernorth Behavioral Health of California, Inc., and Evernorth Behavioral Health of Texas.

Background/context: This form is intended to be completed by a provider who has a thorough knowledge of the Evernorth patient's current clinical presentation and his/her treatment history and is based on the Medical Necessity Criteria for ABA. In filling out the form, providers are invited to do so in lieu of the telephonic clinical review; completing the form may replace the need for a phone-based clinical review.