Evernorth Behavioral Health Prior Authorization Guide 2026
Evernorth (Cigna) behavioral health prior authorization in 2026: inpatient and residential rules, the PHP change, MCG, LOCUS, ASAM criteria, and appeals.
On this page: Direct answer
Direct answer
Evernorth behavioral health prior authorization: what operators need to know
Evernorth (Cigna) behavioral health prior authorization in 2026: inpatient and residential rules, the PHP change, MCG, LOCUS, ASAM criteria, and appeals. Inpatient and residential admissions always need Evernorth prior authorization; IOP depends on the plan. Since January 1, 2025, most Evernorth plans no longer require PHP prior authorization, but a small number still do and network exception requests always do.
Evernorth Behavioral Health is a subsidiary of The Cigna Group and the behavioral network for people with Cigna Healthcare plans. Its March 2026 Administrative Guidelines state the core rule plainly: prior authorization is required for all inpatient and residential admissions under every Evernorth utilization-management model, while partial hospitalization and intensive outpatient programs may require it depending on the plan.
That second clause changed in 2025, when Evernorth dropped PHP prior authorization for most plans, and the criteria map keeps moving: MCG for mental health, LOCUS and CALOCUS-CASII in a growing list of states, and two ASAM editions split by age. Last verified: September 2026, against the March 2026 guidelines and Evernorth's Provider Newsroom.
Marsa Health is not affiliated with, endorsed by, or a partner of Evernorth or Cigna Healthcare; the names identify the payer only. Requirements vary by plan, state, and product, so confirm each one on the member's plan.
Key takeaways
The short version
- Inpatient and residential admissions always need Evernorth prior authorization; IOP depends on the plan.
- Since January 1, 2025, most Evernorth plans no longer require PHP prior authorization, but a small number still do and network exception requests always do.
- Mental health reviews use MCG Behavioral Health Guidelines, except LOCUS and CALOCUS-CASII in California, Colorado, New York, and (from August 29, 2026) Illinois, Maryland, and Oregon.
- Substance use reviews use The ASAM Criteria 4th edition for ages 18 and older and 3rd edition for ages 17 and under.
- Evernorth refuses appeals submitted by automation; each appeal must be submitted by a person.
Take the template with you
Free to copy · no email required
A structure for appealing an Evernorth behavioral health medical-necessity denial against the guideline it cites. Fill it in your secure system; a named person must review and submit it.
1. What Evernorth requires by level of care
| Level or service | Evernorth's published position | Source |
|---|---|---|
| Inpatient psychiatric and inpatient SUD | Prior authorization required for all inpatient admissions | Administrative Guidelines, March 2026 |
| Residential treatment | Prior authorization required for all residential admissions | Administrative Guidelines, March 2026 |
| Partial hospitalization | No prior authorization on most plans; a small number still require it; network exception requests do | Provider Newsroom, effective January 1, 2025 |
| Intensive outpatient | May require prior authorization depending on the plan | Administrative Guidelines, March 2026 |
| Applied behavior analysis | Prior authorization typically required; most requests go to the Autism Utilization Management team | Administrative Guidelines, March 2026 |
| Psychological testing | Clinical review generally not required for covered diagnoses, though some plans require it; neuropsychological testing typically falls under medical coverage | Administrative Guidelines, March 2026 |
| Office-based buprenorphine | Induction and ongoing medication management do not typically require prior authorization | Administrative Guidelines, March 2026 |
2. How to request authorization
- 01
Look up the code first
On Provider.Evernorth.com you can verify eligibility, generate a benefit reference number, and look up a procedure code to see whether prior authorization is required. Evernorth's Prior Authorization and Billing Resource Guide lists requirements but does not replace the eligibility check.
- 02
Submit electronically or by phone
The guide's contact table lists two ways to request prior authorization: an electronic data interchange vendor, or Provider Services at 800.926.2273. The portal handles the requirement lookup and preservice prior authorization appeals. Advocates and care managers are available 24/7 for clinical emergencies.
- 03
Send a complete clinical picture
Evernorth typically asks for diagnosis with ICD-10-CM code, requesting and servicing providers, pertinent history and justification, admission or start date, anticipated length of stay, other coverage, place of service and level of care, and a preliminary discharge plan.
- 04
Emergency admissions
If acuity does not allow prior authorization, contact Evernorth as soon as possible with the history and nature of the crisis, alternatives considered, treatment goals, estimated length of stay, and discharge plan.
- 05
Late inpatient requests
Retrospective inpatient requests get a real-time decision when submitted within four calendar days of admission or on the last covered day; later requests go to a care manager for a more detailed review.
3. MCG, LOCUS, CALOCUS-CASII, and ASAM: which applies
Cigna stopped using its own Standards and Guidelines for mental health on November 27, 2020, when it moved to MCG. Evernorth adopted LOCUS and CALOCUS-CASII to comply with California SB 855 and New York's Part 514 regulations, and its August 2026 notice says the medical necessity review process itself is not changing.
| Population or service | Criteria Evernorth names | Where it applies |
|---|---|---|
| Mental health levels of care (default) | MCG Behavioral Health Guidelines, 30th edition | All health plan business unless contract, federal, or state law requires other criteria |
| Mental health, ages 19 and older | LOCUS | Commercial plans in California, Colorado, and New York; Illinois, Maryland, and Oregon commercial and individual plans from August 29, 2026 |
| Mental health, ages 6 to 18 | CALOCUS-CASII | The same states as LOCUS |
| Substance use disorder, ages 18 and older | The ASAM Criteria, 4th edition | All health plan business unless law or contract says otherwise |
| Substance use disorder, ages 17 and under | The ASAM Criteria, 3rd edition | All health plan business, same exceptions |
| Autism, ABA, and TMS | Evernorth and Cigna Healthcare coverage policies | Coverage Policies page on Provider.Evernorth.com |
4. Coverage denials: peer-to-peer first, then appeal
Evernorth strongly encourages sending clinical information before the peer-to-peer or appeal. After an adverse determination that follows a peer-to-peer review, a review is available with a physician not previously involved: an Evernorth-contracted, board-certified psychiatrist or doctoral-level psychologist. It can run expedited, when the situation is urgent and the patient is still at that level of care, or standard, when the medical record or a treatment summary can be added.
Every Evernorth adverse determination must state the specific guideline relied on (MCG, LOCUS, CALOCUS-CASII, The ASAM Criteria, or the plan coverage policy), the facts and evidence considered, and the clinical rationale. Quote all three at the top of your appeal.
| Step | Evernorth default | Check |
|---|---|---|
| First-level appeal of a coverage denial | Within 180 calendar days of the claim denial | Plan documents or state regulation can set a different window |
| Out-of-network standard appeal | May need an Appointment of Representative form signed by the patient | Call the number on the ID card to confirm |
| Second-level appeal | Within 60 days of receiving the first-level decision letter | Some plans route this to state external review |
| Payment dispute appeal | In writing within 180 calendar days; most resolved in 60 days, with notice within 75 | State law can change both clocks |
| Medical-necessity payment appeal | Include the complete facility record: orders, progress notes, history and physical, consults, test results, discharge summary | A clinician reviews the non-pricing part |
5. Evernorth requires a person to submit each appeal
The March 2026 guidelines say appeal requests may not be submitted with automation software or systems, including automated electronic faxes, and that each appeal must be submitted by a person, whether you send it or a billing service does. Evernorth will notify you to resubmit an appeal it rejects for automation.
That rule fits a sound workflow anyway: software can assemble the evidence and draft the letter, but a named person reviews, signs, and submits it. Record who submitted each appeal, when, and through which channel.
6. Federal and state overlays
- Employer plans under ERISA: urgent decisions within 72 hours, pre-service decisions within 15 days, urgent concurrent extensions within 24 hours when requested at least 24 hours before the approval ends, and at least 180 days to appeal
- Individual plans sold on a Federally Facilitated Exchange: CMS-0057-F requires a specific reason for each prior authorization denial beginning in 2026
- Any Medicare Advantage or Medicaid managed care product: CMS-0057-F adds 72-hour expedited and 7-calendar-day standard decision clocks
- MHPAEA: group plans must provide MH/SUD medical-necessity criteria to contracting providers on request; Evernorth posts its criteria on the Coverage Policies page, where some policies require a login
- State law: Evernorth says it complies with state-specific laws as written, so check the member's state before choosing a criteria set
7. Residential admission packet for Evernorth
- Eligibility and benefit reference number from Provider.Evernorth.com, with the date checked
- The criteria set that applies: MCG (or LOCUS/CALOCUS-CASII in listed states) for mental health; ASAM 3rd or 4th edition by age for SUD
- Diagnosis with ICD-10-CM code, requesting and servicing provider, and place of service
- Why residential and not PHP or IOP, in the vocabulary of the applicable criteria
- Anticipated length of stay and a preliminary discharge plan naming the next level of care
- For Cigna Connect members, confirmation that the facility is in network for the member's state
Common questions
Answers before you build.
Does Evernorth require prior authorization for PHP?+
Not on most plans. Evernorth removed PHP prior authorization for most plans effective January 1, 2025; a small number of plans still require it, and PHP network exception requests always do. Check the member's plan on Provider.Evernorth.com or with Provider Services.
Does Evernorth require prior authorization for IOP?+
It depends on the plan. The March 2026 guidelines say partial and intensive outpatient programs may require prior authorization depending on the plan. Look up the code on the portal before the first day.
Which criteria does Evernorth use for mental health residential treatment?+
MCG Behavioral Health Guidelines by default, or LOCUS (19 and older) and CALOCUS-CASII (6 to 18) for commercial plans in California, Colorado, and New York, and for commercial and individual plans in Illinois, Maryland, and Oregon from August 29, 2026.
Can a billing vendor submit Evernorth appeals automatically?+
No. Evernorth says appeal requests may not be submitted with automation software or systems and that each appeal must be submitted by a person, including when a third-party billing service files on your behalf.
How long do I have to appeal an Evernorth behavioral health denial?+
Evernorth's default is 180 calendar days from the claim denial for a first-level appeal, unless the plan or state sets a different window, and 60 days from the first-level decision letter for a second level. The denial letter controls.
Practical closeout
Use this operator checklist.
- Inpatient and residential admissions always need Evernorth prior authorization; IOP depends on the plan.
- Since January 1, 2025, most Evernorth plans no longer require PHP prior authorization, but a small number still do and network exception requests always do.
- Mental health reviews use MCG Behavioral Health Guidelines, except LOCUS and CALOCUS-CASII in California, Colorado, New York, and (from August 29, 2026) Illinois, Maryland, and Oregon.
- Substance use reviews use The ASAM Criteria 4th edition for ages 18 and older and 3rd edition for ages 17 and under.
- Evernorth refuses appeals submitted by automation; each appeal must be submitted by a person.
Continue through the cluster
Verified customer case studies are added only with customer permission and supporting evidence; none is implied by these operational examples.
Sources & methodology
Trace the operational claims.
Marsa Health Editorial reviewed the primary and research sources below on September 21, 2026. We translate them into workflow controls, distinguish proposals from final rules, and flag where plan, program, state, contract, or clinical requirements vary.
- 01Evernorth Behavioral Health Administrative Guidelines (March 2026) Evernorth Behavioral HealthPrior authorization protocol by level of care, emergency and retrospective requests, ABA and testing rules, medical necessity criteria, coverage-denial appeals, and the no-automation rule for appeal submission.Accessed or rechecked September 21, 2026
- 02Update to Prior Authorization Requirements for Partial Hospitalization Level of Care Effective January 1, 2025 Evernorth Behavioral Health (Provider Newsroom)December 10, 2024 notice, updated January 16, 2025: PHP prior authorization removed for most Evernorth plans; network exception requests still require it.Accessed or rechecked September 21, 2026
- 03Annual Review of Behavioral Health Medical Necessity Criteria Evernorth Behavioral Health (Provider Newsroom)Published June 12, 2025 and updated April 13, 2026: MCG Behavioral Health Guidelines (30th edition), ASAM 3rd and 4th edition age split, and LOCUS states.Accessed or rechecked September 21, 2026
- 04LOCUS and CALOCUS-CASII Criteria Adoption in Illinois, Maryland, and Oregon Evernorth Behavioral Health (Provider Newsroom)August 24, 2026 notice: LOCUS and CALOCUS-CASII adopted for commercial and individual plans in three more states effective August 29, 2026.Accessed or rechecked September 21, 2026
- 05Medical Necessity Criteria Evernorth Behavioral HealthEvernorth's public index of the criteria sets it uses for behavioral health medical necessity reviews.Accessed or rechecked September 21, 2026
- 06CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) Fact Sheet Centers for Medicare & Medicaid ServicesImpacted payers, 72-hour expedited and seven-calendar-day standard decision timeframes (not applicable to FFE QHP issuers), specific denial reasons beginning in 2026, and January 1, 2027 API requirements.Accessed or rechecked September 21, 2026
- 0729 CFR 2560.503-1: Claims Procedure Legal Information Institute (Cornell Law School)Federal claims rule for ERISA group health plans: 72-hour urgent and 15-day pre-service decisions, 24-hour urgent concurrent extensions, and at least 180 days to appeal.Accessed or rechecked September 21, 2026
- 0829 CFR 2590.712: Parity in Mental Health and Substance Use Disorder Benefits Legal Information Institute (Cornell Law School)Paragraph (d) requires group health plans to provide MH/SUD medical-necessity criteria on request to participants and contracting providers, and to make denial reasons available.Accessed or rechecked September 21, 2026
Organizational author. Editorial review covers source accuracy, search intent, workflow boundaries, and human-oversight requirements. This material is educational and does not provide clinical, legal, coding, or coverage advice.
No named clinical or legal expert reviewer is attributed to this version. Marsa Health does not invent reviewer credentials.
Read our editorial methodRevision history
What changed and when
September 21, 2026
Initial publication, source review, and operational editing.