Cigna prior authorization for behavioral health and substance use care

1. Who reviews: Cigna or Evernorth

The card says Cigna, but behavioral health authorizations go to Evernorth. Cigna's precertification page for providers sends behavioral health requests to Evernorth's authorization and billing resource, a grid of codes that says, code by code, whether authorization is required, not required, or "dependent upon benefit plan." Evernorth also runs the behavioral health network, so your contract, your network status and your authorizations all sit with Evernorth, not with the medical side of Cigna. That split is a behavioral health carve-out in everything but name, and it's why a medical precertification number gets you nowhere for an IOP admission.

This page covers Cigna Healthcare's commercial plans: employer plans, including self-funded ones Cigna administers, and individual plans. Cigna no longer runs Medicare Advantage (see section 8).

2. Which levels of care need prior authorization

What Evernorth's own documents say as of October 2026. Evernorth adds that requirements depend on the member's benefit plan, and its provider portal at Provider.Evernorth.com lets you look up a procedure code for a member to see the cost share and whether prior authorization is required. Do that, or call, for every admission.

Level of care	Prior authorization	What Evernorth says
Emergency behavioral health	Not required	Cigna's precertification page says emergency behavioral health services don't need precertification, but an emergency that results in an inpatient admission must be reported within one business day of the admission unless a state mandate says otherwise.
Inpatient, including inpatient detox (withdrawal management)	Required	Evernorth's Inpatient Prior Authorization Form (rev. 12/2025) covers initial requests for inpatient behavioral and substance use services; it gives the fax number, and says to call 800.926.2273 if you can't fax.
Residential treatment	Required	The billing grid lists residential (revenue codes 1001 and 1002) as requiring authorization. Evernorth's behavioral health forms page has a Residential Prior Authorization Request Form, updated June 9, 2026.
Partial hospitalization (PHP)	Depends on the plan	The grid marks PHP as dependent on the benefit plan, with "call to verify." Cigna's precertification page gives 1 (800) 926-2273 for inpatient and partial hospitalization. An out-of-network program asking for in-network treatment uses the PHP Network Exception Request Form.
Intensive outpatient (IOP)	Usually not	Evernorth's IOP request form says prior authorization for IOP ended May 1, 2022, in and out of network, and not to send a form. The grid still says to verify by plan. Out-of-network programs wanting in-network treatment use the IOP Network Exception Request Form.
Outpatient therapy	Not listed as required	The grid lists psychotherapy codes 90834 and 90837 with no authorization requirement, and the IOP form notes that group psychotherapy (90853) doesn't need one.
Psychological and neuropsychological testing	Depends on the plan	The grid lists the testing codes with "call to verify."
TMS	Not for contracted providers, on most plans	Evernorth's TMS prior authorization removal FAQ: from March 6, 2026, no prior authorization for TMS from Evernorth-contracted providers. Non-contracted providers still need it.
ABA (autism)	Required	Evernorth's ABA prior authorization form covers treatment; for standard requests, the assessment codes 97151, 97152 and 0362T no longer need prior authorization.

We didn't find a separate rule for ambulatory (outpatient) withdrawal management in Evernorth's public documents. Ask on the call, and write down the answer with the rep's name and a reference number. Our detox and residential VOB guide covers which benefit those levels fall under.

3. How to request it

1. Find the plan's rule first. Look up the codes on Provider.Evernorth.com, or call Evernorth. Run the benefits check and the rep questions from our VOB call script, and ask for each level you might use, not just the one you're admitting to.
2. Call 1 (800) 926-2273 for inpatient and PHP. That's the number on Cigna's precertification page; Evernorth's forms give the same number as provider services and as the fallback when you can't fax.
3. Or send the form for the level. Evernorth's behavioral health forms page has the inpatient and residential prior authorization forms and the network exception forms for out-of-network IOP, PHP and outpatient care. Each form prints its own fax number. Some states have their own forms (Evernorth publishes state forms for Massachusetts and West Virginia, among others), so check the forms page for the member's state.
4. Don't expect Cigna's medical portal to take it. Cigna's 2025 guide to its online precertification tool says the tool didn't yet take behavioral health precertification. Use Evernorth's phone line and forms.
5. Write down the reference or authorization number, the care manager's name, the level and days or visits approved, the first and last approved day, and the date of the next review.

4. The criteria the reviewer uses

Evernorth publishes which criteria it uses, on its medical necessity criteria page:

• Substance use disorders: the ASAM Criteria. Evernorth's ASAM Criteria page says it moved to the 4th edition for members 18 and older in November 2024, and uses the 3rd edition for members 17 and under. Rate the six dimensions with the edition that matches the client's age; the dimensions are listed in our prior authorization guide.
• Mental health: MCG Behavioral Health Guidelines, unless a contract or a federal or state law requires other criteria.
• LOCUS and CALOCUS-CASII where state law requires them. Evernorth's LOCUS page ties its use to state laws, such as California's 2020 Senate Bill 855, and applies LOCUS to adults 19 and older and CALOCUS-CASII to ages 6 to 18.

The full LOCUS and CALOCUS-CASII documents sit behind a provider login. If the reviewer cites a criterion you can't see, ask for it: under federal parity rules a plan must make its mental health and substance use medical necessity criteria available to a contracting provider on request (our parity guide covers what to ask).

5. Continued-stay reviews

Evernorth's inpatient form is for initial requests only. After that, the stay goes through concurrent review with an Evernorth care manager; ask at the first review when the next one is due. Evernorth's clinical review guides list what each review covers, with separate outlines for inpatient (general, child and adolescent, eating disorder, substance use), intensive outpatient and outpatient care. For concurrent reviews, the higher-level-of-care outline asks for anything not given at the first review, including:

• the reason for admission, and current medications and changes;
• family sessions held or planned;
• measurable treatment goals and progress on them;
• barriers to discharge and the discharge plan;
• for partial programs, how the client is using skills outside program hours.

Give discharge information at the last review. Schedule each review before the last approved day, with an owner, and write it from this week's notes, not last week's; the continued-stay section of our general guide has the full list reviewers look for.

6. How long Cigna has to decide

We didn't find a decision time for behavioral health requests in Evernorth's public provider documents. Federal and state law set the outer limits, and which one applies depends on the plan:

Plan type	Deadline	Source
Employer plans (ERISA, including self-funded)	Urgent: as soon as possible, no later than 72 hours. Non-urgent before care: no later than 15 days, with one 15-day extension allowed. A request to extend an urgent course of treatment made at least 24 hours before it ends: within 24 hours.	29 CFR 2560.503-1
Fully insured plans regulated by a state	State law can set shorter deadlines. Texas's are in our prior authorization guide.	Your state insurance department
Individual marketplace plans on the federal exchange	Not covered by CMS's 2026 deadlines of 7 days and 72 hours, which exclude qualified health plans on the federal exchanges.	CMS-0057-F

For a client already in care, ask for the continued-stay review early. Under the federal rule, an urgent extension request made at least 24 hours before the approved period ends gets a 24-hour answer; a late one doesn't.

7. Peer-to-peer reviews and appeals

• Peer-to-peer. Cigna's behavioral health provider manual describes a peer-to-peer review in clinical cases, and says that when it ends in a denial, a review is available with a physician not previously involved in the case. For an outpatient network exception, Cigna's request form says that when the medical director finds the request doesn't meet medical necessity criteria, they issue a denial and offer a live peer-to-peer review. Ask for one as soon as the care manager says the case is going to a physician reviewer.
• Appeals. Evernorth's administrative guidelines say appeals must be filed within 180 days of the initial denial, and appeals of clinical denials go to the contact in the denial letter. The Evernorth Behavioral Health appeals form goes to its Central Appeals Unit and notes that a plan may allow longer.
• Urgent appeals. For employer plans, federal rules give an urgent appeal a decision within 72 hours, and at least 180 days to file any appeal. Ask for the expedited track when the client is still in care.

Build the appeal from the plan's own criteria: the ASAM dimension ratings with dates and facts, or the MCG or LOCUS items, answered point by point. Cima EHR's guide to appealing an insurance denial has a letter structure.

8. Commercial, Medicare Advantage and Medicaid

Product	Who reviews behavioral health	What to know
Cigna commercial (employer and individual plans)	Evernorth Behavioral Health	Everything above. Self-funded employer plans follow federal law and their plan documents, which can add or drop requirements; the code lookup and the call tell you.
Medicare Advantage	No longer Cigna	The Cigna Group completed the sale of its Medicare Advantage and Part D businesses on March 19, 2025. Use the plan name and phone number on the member's current card. Older Cigna Medicare documents still online (one asked for notice within 24 hours of an admission) describe the business that was sold.
Medicaid	The state's Medicaid plan on the card	This page doesn't cover Medicaid. Verify with the plan on the card; our Medicaid and Medicare eligibility guide shows how to find it.

9. Before you call: a checklist

• The card: photos of both sides, the member ID, the group number and the behavioral health phone number on the back.
• Network status: are you in Evernorth's network for this level of care? If not, which network exception form applies (IOP, PHP or outpatient)? A single-case agreement is a separate conversation.
• The codes: the revenue code and HCPCS or CPT code for the level, so the rep or the code lookup can give a code-level answer.
• The clinicals: diagnosis with ICD-10 code; substances, amount, frequency and last use; withdrawal history; medications; risk to self or others; treatment history with dates; the recovery environment.
• The ratings: all six ASAM dimensions (4th edition for adults, 3rd for 17 and under), or the MCG or LOCUS items for a mental health level.
• The plan of care: the schedule (hours and days a week), the expected length of stay, the goals and the discharge plan.
• Your log: the date and time, the rep or care manager, the reference number, and the next review date. The VOB checklist and the printable VOB form have a box for each.

Quick VOB keeps that log for you: what the rep said for each level of care, with the reference number, and each authorization tracked to its last day with an email 5 days before it ends. Programs that want the continued-stay reviews on the chart too use Cima EHR for IOP and PHP programs. Getting in network with Evernorth first? See Cima Consulting's Cigna and Evernorth credentialing guide.

Other insurers: Aetna prior authorization · Humana prior authorization · prior authorization for any plan

Questions

Does Cigna require prior authorization for IOP?

Usually not. Evernorth's IOP request form says prior authorization for intensive outpatient care ended May 1, 2022, for in-network and out-of-network providers. Its billing grid still says to verify by benefit plan, so look up the code on Provider.Evernorth.com or call before each admission. An out-of-network program that wants in-network treatment sends the IOP Network Exception Request Form.

Does Cigna require prior authorization for partial hospitalization (PHP)?

It depends on the member's benefit plan; Evernorth's grid says to call to verify. Cigna's precertification page gives 1 (800) 926-2273 for inpatient and partial hospitalization requests.

What is the Cigna prior authorization phone number for behavioral health?

Cigna's provider precertification page lists 1 (800) 926-2273 for inpatient and partial hospitalization programs, and Evernorth's forms give the same number for provider services. The member's card also has a behavioral health number; use it if it's different.

Does Cigna require prior authorization for residential treatment or detox?

Yes, for residential treatment and inpatient care, including inpatient detox. Evernorth has an Inpatient Prior Authorization Form for initial inpatient behavioral and substance use requests and a separate Residential Prior Authorization Request Form. Emergency care needs no precertification, but an emergency inpatient admission must be reported within one business day unless state law says otherwise.

Does Cigna require prior authorization for TMS?

Not for Evernorth-contracted providers on most plans, from March 6, 2026. Non-contracted providers still need prior authorization, and an out-of-network claim can still be reviewed for medical necessity.

Does Cigna require prior authorization for ABA therapy?

Yes, for ABA treatment. For standard requests, the assessment codes 97151, 97152 and 0362T no longer need prior authorization.

What criteria does Cigna use for substance use disorder authorizations?

The ASAM Criteria: the 4th edition for members 18 and older since November 2024, and the 3rd edition for members 17 and under. For mental health levels of care Evernorth uses MCG Behavioral Health Guidelines, or LOCUS and CALOCUS-CASII where a state law requires them.

How long does Cigna prior authorization take?

Evernorth's public documents don't publish a decision time. For employer plans, federal rules allow up to 72 hours for urgent requests and 15 days for non-urgent ones before care, and 24 hours for an urgent extension asked for at least 24 hours before the approved period ends. State law can be shorter for fully insured plans.

Sources

1. Cigna Healthcare, "Precertifications and prior authorizations" (providers). cigna.com
2. Evernorth Behavioral Health, Authorization and billing resource. evernorth.com
3. Evernorth, Behavioral health forms (residential prior authorization form, network exception forms, state forms); Inpatient Prior Authorization Form, rev. 12/2025. evernorth.com · evernorth.com
4. Evernorth, Intensive Outpatient Program (IOP) Request Form, rev. 03/2022; IOP Network Exception Request Form. evernorth.com · evernorth.com
5. Evernorth, TMS prior authorization requirement removal (FAQ). cigna.com
6. Evernorth, Applied Behavior Analysis Prior Authorization Form. evernorth.com
7. Evernorth, Medical necessity criteria; The ASAM Criteria; LOCUS criteria. evernorth.com · evernorth.com · evernorth.com
8. Evernorth, Clinical review guides. evernorth.com
9. Evernorth Behavioral Health, Administrative guidelines; Cigna Behavioral Health provider manual; Evernorth Behavioral Health appeals form. evernorth.com · evernorth.com · cigna.com
10. Cigna Healthcare, Online precertification guide (2025). cigna.com
11. The Cigna Group, press release on completing the sale of its Medicare businesses (March 19, 2025). thecignagroup.com
12. 29 CFR 2560.503-1, Claims procedure (employer group health plans). ecfr.gov
13. CMS, Interoperability and Prior Authorization Final Rule (CMS-0057-F). cms.gov

General information, not legal, clinical or billing advice. Quick VOB isn't affiliated with Cigna or Evernorth. Requirements differ by plan and state and change during the year; check the member's plan, Evernorth's current documents and your contract before each admission.