Effective April 1, 2025, Evernorth^® Behavioral Health (Evernorth) will adopt the MCG Behavioral Health Guidelines for applied behavior analysis (ABA) level of care in Virginia. 

Developed by MCG Health^®, the guidelines will be used to conduct ABA level of care medical necessity reviews for all commercial health plans in Virginia, unless contractual requirements or federal or state law require the use of other specifically identified clinical criteria.

What this means to you

Adoption of MCG Behavioral Health Guidelines further supports a consistent application of evidence-based criteria to ensure that treatment includes consideration of practices that have been shown to be most effective for mental health disorders. These guidelines complement our suite of existing evidence-based criteria to support your clinical judgment and decision-making processes.

Please note that we are only changing the source of our criteria for the ABA level of care. Our medical necessity review process is not changing, and we will continue to use the following resources to make determinations when appropriate:

• The American Society of Addiction Medicine (ASAM) Criteria^®
  We use this criteria for guidance in conducting medical necessity reviews of substance use disorder level of care for all commercial health plans.
• Evernorth and Cigna Healthcare^SM coverage policies
• Evernorth Behavioral Health Authorization and Billing Resource
• State and federal regulations and licensing standards

Additionally, ABA assessment Current Procedural Terminology (CPT^®) codes (97151, 97152, and 0362T) will continue to not require prior authorization. Network exception requests for ABA assessments can be requested by submitting the Applied Behavior Analysis (ABA) Network Exception Request for Initial Assessment form on the Provider.Evernorth.com portal (Resources > Forms Center > Behavioral Health Forms).

Online resources

You can access our evidence-based criteria, clinical support tools, and resources, including the MCG Behavioral Health Guidelines on the Provider.Evernorth.com portal (Coverage Policies, see Supporting Behavioral Websites).

Additional information

If you have any questions, please call the Autism Care Coordinator team at 877.279.7603.