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Evernorth forms cover a range of administrative and clinical documents required by Evernorth Behavioral Health and its affiliated health plans. The forms in this category are specifically focused on prior authorization for Applied Behavior Analysis (ABA) therapy — a structured, evidence-based treatment primarily used for individuals diagnosed with Autism Spectrum Disorder (ASD). These documents are a mandatory step before ABA services can be covered under a patient's Evernorth health plan, making them essential to the treatment process.
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About Evernorth forms
These forms are typically completed by supervising clinicians, behavioral health providers, and ABA therapy practices on behalf of their patients. Situations that require them include initial treatment requests, continued stay reviews, reconsiderations, and network exception requests. Providers must supply detailed clinical information — including diagnosis codes, assessment scores, requested CPT codes, service hours, and supporting documentation demonstrating medical necessity — all of which must be accurate and complete to avoid delays in authorization.
Given how detailed and time-sensitive these forms can be, tools like Instafill.ai use AI to fill them out in under 30 seconds, handling the data accurately and securely — a practical time-saver for busy clinical and administrative staff.
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How to Choose the Right Form
Both forms on this page are designed for ABA (Applied Behavior Analysis) prior authorization with Evernorth, but they serve slightly different situations. Here's how to pick the right one:
Requesting Authorization for a New or Ongoing ABA Treatment Plan
- Evernorth Applied Behavior Analysis (ABA) Prior Authorization Form (928213d) is the standard go-to form for supervising providers submitting authorization requests for ABA services for patients diagnosed with Autism Spectrum Disorder (ASD). It covers initial requests and includes fields for standardized assessment scores, treatment history, requested service codes and hours, and coordination of care — replacing the traditional phone-based clinical review process.
Initial, Continued Stay, Reconsideration, or Network Exception Requests
- Evernorth Behavioral Health Applied Behavior Analysis Prior Authorization Form (PCOMM-2025-224) is the right choice if you need to submit not just an initial request, but also a continued stay review, reconsideration, or network exception request. It's the more comprehensive option when your situation goes beyond a standard first-time authorization.
Quick Decision Summary
- New or ongoing ABA authorization? → Use the ABA Prior Authorization Form (928213d)
- Continued stay, reconsideration, or network exception? → Use the PCOMM-2025-224 form
- Unsure which applies? → The PCOMM-2025-224 covers more request types, making it the safer choice if your situation is complex
Both forms can be filled out quickly using AI-powered tools on Instafill.ai, which can also convert non-fillable PDF versions into interactive forms — saving clinicians and office staff significant time.
Form Comparison
| Form | Purpose | Who Files It | When to Use |
|---|---|---|---|
| Evernorth Behavioral Health Applied Behavior Analysis Prior Authorization Form (PCOMM-2025-224) | Request prior authorization for ABA therapy services | Clinicians providing ABA therapy | Initial, continued stay, reconsideration, or network exception requests |
| Evernorth Applied Behavior Analysis (ABA) Prior Authorization Form | Request authorization for ABA treatment, replacing telephonic review | Supervising providers overseeing ABA treatment | New or ongoing ABA authorization for ASD patients |
Tips for Evernorth forms
Evernorth has multiple ABA prior authorization forms, and submitting the wrong version can cause delays or denials. Check the form number (e.g., PCOMM-2025-224 or 928213d) against what Evernorth currently accepts before you begin filling it out. Using an outdated form may require you to restart the entire process.
These forms require detailed clinical information including diagnosis codes, standardized assessment scores, CPT codes, and requested service hours. Having all supporting documentation — such as the patient's ASD diagnosis records and treatment history — ready before you begin will prevent incomplete submissions. Incomplete forms are a leading cause of authorization delays.
Both forms require accurate provider information, including supervising clinician credentials and National Provider Identifier (NPI) numbers. Errors in this section can trigger a rejection even if the clinical information is complete. Verify all provider details against your credentialing records before submitting.
Evernorth's ABA forms ask for specific CPT codes and the number of hours requested per service type. Mismatched or unsupported codes are a common reason for prior authorization denials. Consult Evernorth's current ABA billing guidelines to ensure the codes and hours you request align with their coverage policies.
AI-powered tools like Instafill.ai can fill out Evernorth ABA prior authorization forms quickly and accurately, saving providers significant administrative time — especially when managing multiple patient authorizations. Instafill.ai also converts non-fillable PDF versions into interactive forms, and your data stays secure throughout the process. For busy practices, this can be a major time-saver.
Evernorth requires clinical justification demonstrating medical necessity for ABA therapy coverage. Vague or generic clinical notes are frequently cited in denials, so include specific assessment results, behavioral goals, and evidence-based rationale. The stronger your clinical narrative, the smoother the authorization process tends to be.
Prior authorization requests can take time to process, and delays can interrupt a patient's ABA therapy services. Keep a record of your submission date and confirmation, and follow up with Evernorth if you haven't received a response within their stated review timeframe. Proactive tracking helps avoid gaps in care for patients with ASD.
Frequently Asked Questions
Evernorth forms are official documents used by healthcare providers and patients to interact with Evernorth's health plan and behavioral health services. The forms currently available in this category are specifically related to requesting prior authorization for Applied Behavior Analysis (ABA) therapy services for individuals diagnosed with Autism Spectrum Disorder (ASD).
Supervising clinicians and behavioral health providers who plan to deliver ABA therapy to patients covered under an Evernorth health plan are required to submit these forms. Prior authorization must be obtained before services begin to ensure coverage under the patient's plan.
Both forms serve the purpose of requesting prior authorization for ABA services, but they differ in version and scope. Form PCOMM-2025-224 specifically covers initial requests, continued stay, reconsideration, and network exception requests, while Form 928213d (ABA Prior Authorization Form) is designed to replace the traditional telephonic clinical review process with a comprehensive written submission. Providers should confirm with Evernorth which form applies to their specific plan or submission scenario.
These forms support a range of authorization request types, including initial authorization for new ABA treatment, continued stay or ongoing service requests, reconsideration requests if a prior authorization was denied, and in some cases network exception requests. The specific request types available may vary by form version.
Providers generally need to supply patient demographics, ASD diagnosis details, standardized assessment scores, treatment history, requested CPT service codes and hours, place of service, provider credentials, and supporting clinical documentation demonstrating medical necessity. Having this information ready before starting the form helps ensure a complete and accurate submission.
Completed forms are typically submitted directly to Evernorth Behavioral Health through their designated submission channels, which may include fax, an online provider portal, or mail. Providers should refer to the contact or submission instructions included with the specific form or check Evernorth's provider resources for the most current submission details.
Prior authorization should generally be requested before ABA services begin, as treatment provided without an approved authorization may not be covered. Providers are advised to submit requests with enough lead time to allow for Evernorth's clinical review process, and to check Evernorth's guidelines for any specific timeframes related to continued stay or reconsideration requests.
Yes, AI-powered tools like Instafill.ai can fill out Evernorth ABA prior authorization forms in under 30 seconds by accurately extracting and placing data from source documents such as patient records and clinical assessments. Instafill.ai can also convert non-fillable PDF versions of these forms into interactive, fillable formats, making the process faster and reducing manual data entry errors.
Manually completing an Evernorth ABA prior authorization form can take considerable time due to the volume of clinical information required across multiple sections. Using AI-assisted tools like Instafill.ai, the same forms can be accurately populated in under 30 seconds, significantly streamlining the administrative workload for busy provider offices.
These forms are specifically designed for patients covered under Evernorth behavioral health plans that include ABA therapy benefits. Coverage and form requirements may vary depending on the specific plan, so providers should verify with Evernorth or the patient's plan administrator which form and process applies before submitting.
After submission, Evernorth's behavioral health team conducts a clinical review to assess medical necessity based on the information provided. Providers and patients are typically notified of the authorization decision, and if approved, services can proceed under the authorized codes and timeframes. If denied, the forms also support reconsideration requests.
Glossary
- Prior Authorization (PA)
- Approval required from Evernorth before a provider can deliver certain treatments or services and have them covered by the patient's health plan. Without prior authorization, claims for ABA therapy may be denied.
- Applied Behavior Analysis (ABA)
- A therapy approach based on behavioral science, commonly used to improve social, communication, and learning skills in individuals with Autism Spectrum Disorder. ABA is the primary service type covered by these Evernorth forms.
- Autism Spectrum Disorder (ASD)
- A developmental condition affecting communication, behavior, and social interaction, and the primary diagnosis for which Evernorth ABA prior authorization is requested.
- Evernorth Behavioral Health
- The behavioral health division of Evernorth (a subsidiary of Cigna Group) that manages mental health and substance use benefits, including authorization and coverage for ABA therapy services.
- CPT Codes
- Current Procedural Terminology codes are standardized numeric codes used to identify specific medical or therapeutic services being requested. On these forms, providers must list the specific ABA service CPT codes they are seeking authorization for.
- Medical Necessity
- A clinical standard used by Evernorth to determine whether a requested treatment is appropriate and required for the patient's condition. Providers must submit supporting documentation to demonstrate that ABA therapy meets this standard.
- Continued Stay Request
- A type of prior authorization request submitted when a patient is already receiving ABA services and the provider seeks approval to extend or continue that treatment beyond the initially authorized period.
- Network Exception Request
- A request submitted when a provider is outside of Evernorth's approved network, asking for special authorization to deliver covered services to a patient when in-network options are unavailable or insufficient.
- Supervising Provider
- A credentialed clinician, typically a Board Certified Behavior Analyst (BCBA), who oversees ABA treatment and is responsible for submitting the prior authorization form to Evernorth on behalf of the patient.
- Standardized Assessment Scores
- Results from validated diagnostic or behavioral tools (such as the Vineland or ABLLS-R) that providers include on the form to objectively document the patient's current functioning level and support the medical necessity of ABA services.