ABA is a therapy based on the science of learning and behavior. It is typically used to help people with autism spectrum disorder (ASD) and other developmental disorders learn behaviors that help them live safer and more fulfilling lives.

ABA focuses on teaching necessary skills and stopping dangerous behaviors rather than preventing harmless self-stimulatory behavior (stims). Therapists work with individuals with ASD and other developmental disorders to improve skills such as:

• Communication and language abilities
• Social skills
• Self-care and hygiene routines
• Play and leisure skills
• Motor abilities
• Learning and academic skills

Treatment of ASD and Down Syndrome, through speech therapy, occupational therapy, physical therapy, and applied behavior analysis services must be provided by an individual certified pursuant to section 393.17, Florida Statutes, or an individual licensed under Chapter 490 or Chapter 491, Florida Statutes.

These include:

• Certified Behavior Analysts (section 393.17, Florida Statutes)
• Psychologist (Chapter 490, Florida Statues)
• Clinical social worker or mental health counselor (Chapter 491, Florida Statutes)

An eligible individual is defined as an individual under 18 years of age or an individual 18 years of age or older who is in high school and has been diagnosed as having a developmental disability at 8 years of age or younger.

Yes, insurers and HMOs may not deny or refuse to issue coverage for medically necessary services, refuse to contract with, or refuse to renew or reissue or otherwise terminate or restrict coverage for an individual solely because the individual is diagnosed as having a developmental disability. Policy or contract benefits must be applied uniformly, regardless of an individual's medical or developmental history.

If the insurer refuses to pay a claim or denies pre-authorization for a service, you have the right to appeal the decision. Insurers must tell you why they've denied the claim or pre-authorization and they must let you know how you can dispute their decision.

For more details about the internal and external appeal processes, review the Filing an Appeal section.

The State of Florida regulates commercial (individual and group) insurance policies as well as individual and group HMO contracts that are issued in our state. If you have a plan from another state, a Medicare Advantage plan, a Medicaid managed care plan, a self-insured private employer plan, or a governmental health plan, please contact the appropriate state or federal agency for assistance.

Commercial health plan issued in another state
Select the appropriate state - https://content.naic.org/state-insurance-departments

Medicare Parts A and B
Contact Medicare at 1-800-633-4227

Medicare Advantage Plan
Contact Medicare at 1-800-633-4227

Florida Medicaid Managed Care
A complaint should be filed with the health plan first. If unsuccessful, contact:

Agency for Healthcare Administration (AHCA)
1-877-254-1055

File a complaint online at:
http://ahca.myflorida.com/Medicaid/complaints/complaints_provider.shtml

Self-insured non-governmental plans (private employer)
U.S. Department of Labor
Employee Benefit Security Administration
1000 S. Pine Island Road, Suite 100
Plantation, FL 33324
Toll-Free Helpline: 1-866-444-3272
Direct: (954) 424-4022

Self-insured non-federal governmental plans
First contact the local county or city officials but if not resolved, then email the federal Department of Health and Human Services at phig@cms.hhs.gov.

State of Florida employees should contact:
Department of Management Services, Division of State Group Insurance
P.O. Box 5450
Tallahassee, FL 32314-5450
Phone: (850) 921-4600 or 1-800-226-3734
Fax - (850) 488-0252 or (850) 921-4528

Federal employee plans
U.S. Office of Personnel Management
Federal Employee Health Benefit Programs
1900 E. Street NW, Room 3443
Washington, DC 20415-0001
Phone: (202) 606-0727

Tricare (military plans)
Palmetto Government Benefits Administration
Tricare Claims Department
P.O. Box 7031
Camden, SC 29020-7031
Toll Free: 1-800-444-5445 (East Region)
Website Address: https://tricare.mil/PatientResources/ContactUs

Verify the licensure of a Certified Behavior Analyst, Psychologist, Clinical Social Worker or Mental Health Counselor
Florida Department of Health - https://mqa-internet.doh.state.fl.us/MQASearchServices/Home

Apply for Medicaid benefits
https://www.myflfamilies.com/services/public-assistance

Phone numbers for Medicaid Regional offices
https://www.myflfamilies.com/contact-us/

Center for Disease Control
https://www.cdc.gov/ncbddd/autism/index.html

Florida Healthy Kids Program
https://www.floridakidcare.org/
or call 1-888-540-5437 (TTY 1-800-955-8771)

Autism Speaks
https://www.autismspeaks.org/

Autism Society
https://autismsociety.org/

Autism Science Foundation
https://autismsciencefoundation.org/

Easter Seals
https://www.easterseals.com/

Florida State University - Center for Autism &; Related Disabilities
https://fsucard.com/general-info/

Autism Navigator
https://autismnavigator.com/

If your claim or pre-authorization is denied, you have the right to an internal appeal. Some plans have two levels of internal appeals available. You can ask your insurer to conduct a full and fair review of its decision. If the case is urgent, your insurer must speed up this process.

There are 3 steps in the internal appeals process:

1. You or your provider files a claim or request for pre-authorization of a service.
2. Your insurer denies the claim or pre-authorization. Your insurer must notify you in writing and explain why:
   • Within 15 days if you're seeking prior authorization for a treatment
   • Within 30 days for medical services already received
   • Within 72 hours for urgent care cases
3. You file an internal appeal. To file an internal appeal, you need to:
   • Complete all forms required by your insurer, or you can write to your insurer with your name, claim number, and health insurance ID number.
   • Submit any additional information that you want the insurer to consider, such as a letter from the doctor and/or medical records.

You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied. If you have an urgent health situation, notify the insurer at the time of your appeal. If your insurer still denies your claim after exhausting the internal appeals process, you can file for an external review for a denial based on an adverse benefit determination such as medical necessity or an experimental and/or investigational treatment.

How long does an internal appeal take?

• Your internal appeal must be completed within 30 days if your appeal is for a service you haven't received yet.
• Your internal appeal must be completed within 60 days if your appeal is for a service you've already received.

In urgent situations, you can request an external review even if you haven't completed all the insurer's internal appeals processes. You can file an expedited appeal if the timeline for the standard appeal process would seriously jeopardize your life or your ability to regain maximum function.

You have the right to take your appeal to an independent third party for review. External review means that the insurer no longer gets the final say over whether to pay a claim or authorize a service covered under the plan benefits.

There are 2 steps in the external review process:

1. You file an external review: You must file a written request for an external review within four months after the date you receive a notice or final determination from your insurer that your claim or pre-authorization has been denied.
2. External reviewer issues a final decision: An external reviewer either upholds your insurer's decision or decides in your favor. Your insurer is required by law to accept the external reviewer's decision.

Types of denials that can go to external review:

• Any denial that involves medical judgment (medical necessity) where you or your provider may disagree with the insurer, or
• Any denial that involves a determination that a treatment is experimental or investigational.

Denials based on a specific policy or contract exclusion or denied services due to a policy cancellation or termination are not eligible for an external review.

How long does an external review take?

Standard external reviews are decided as soon as possible but no later than 45 days after the request was received.

Expedited external reviews are decided as soon as possible but no later than 72 hours, or less, depending on the medical urgency of the case, after the request was received.

Can someone file an external review for me?

You may appoint a representative (like your doctor or another medical professional) who knows about your medical condition to file an external review on your behalf.

The Department of Financial Services, in conjunction with the Office of Insurance Regulation, regulate the prompt payment of health insurance claims under section 627.6131, Florida Statutes, for insurance companies and section 641.3155, Florida Statutes, for Health Maintenance Organizations (HMOs). If you are experiencing claim payment delay issues that are in violation of our prompt pay laws, please visit our Medical Providers page to request assistance from our office.

Under section 408.7057, Florida Statutes, claims which involve a dispute regarding whether payment should be made or the amount of a payment, should be referred to the Statewide Provider and Health Plan Claim Dispute Resolution Program (Maximus). The Agency for Health Care Administration (AHCA) contracts with Maximus to administer this dispute resolution program. You may obtain information regarding the claim dispute resolution process by calling Maximus toll-free at 1-866-763-6395.

Disputes involving the reimbursement rates for individual providers is considered a private, contractual matter that needs to be addressed between the parties involved.