Community Care Plan ABA / BA coverage (Florida MMA plan).

Under 21, and CCP states it from both directions: its BA provider manual authorizes services for “Medicaid Ages 0-21,” and its service exclusions open with “any Medicaid member 21 years old and over.” That tracks the state benefit exactly — Florida Medicaid BA is for recipients under the age of 21, with EPSDT available above the coverage-policy and fee-schedule limits.^[1][2]

No autism diagnosis is required. CCP publishes the cycle precisely: “the behavior reassessment is required every 6 months”; “the core standardized behavior instruments are only required on an annual basis unless a new behavior emerges or additional hours are requested”; and the reassessment must “be submitted at least 10 days but not more than 30 days prior to the last day of the previously certified service” — so a renewal filed too early is as much a problem as one filed too late. Modifications are never authorized retrospectively.^[1][2]

CCP requires a “prescription or referral form” issued “by an independent physician or practitioner qualified to assess and diagnose disorders related to functional impairments,” including the diagnosis and an order for BA services, plus the Comprehensive Diagnostic Evaluation. It then adds a signature-block rule that intake should treat as a document check: “all practitioner’s signature must include their NPI, credentials and date of signature as defined in Chapter 668, Part I, F.S. Please ensure that the referring provider’s (physician/ARNP/P.A.) LMN, prescription or referral form includes their NPI, credentials and date of signature” — note that CCP names ARNPs and PAs, which the state referral list does not.^[1][2]

“2 core standardized behavior instruments required (required once a year)”: the Vineland-3 Comprehensive Parent Interview Form for all recipients plus the Maladaptive Behavior Domain for ages 3 and older, and the BASC-3 PRQ for recipients ages 2 through 18 — with “additional assessment tools… at the lead analyst’s discretion,” and administration, scoring and reporting all documented in the behavior assessment. The behavior plan must also identify the functions of behavior “based on a Functional Analysis (FA), brief FA, precursor FA or conditional probability.”^[1][2]

Required, and it is the first item on CCP’s own checklist for authorizing the behavior assessment: the prescription or referral form from an independent physician or qualified practitioner, carrying the diagnosis and an order for BA services, plus the CDE. Everything on the Florida BA fee schedule needs prior authorization from Therapy Network of Florida — “behavior assessments, behavior reassessments, behavior intervention/treatment, modification request and all codes on the Florida BA Fee Schedule require prior authorization by Therapy Network” — via the portal at asp.healthsystemone.com/hs1providers, with fax as an emergency backup. Standard approvals land within 5 calendar days, expedited within 2.^[1][2]

Follows the Florida Medicaid rule: the only telemedicine provision is up to two hours per week of Lead Analyst caregiver training (97156) under Rule 59G-1.057, F.A.C. CCP’s BA provider manual publishes no telehealth section, and “any services not included on the Florida Behavior Analysis Fee Schedule” are non-covered — so a telehealth line that is not on that schedule will not pay.^[2][1]

Ask the plan: Therapy Network of Florida provider relations (1-888-550-8800, option 2) before scheduling any remote session other than 97156 caregiver training.

Therapy Network of Florida decides CCP’s BA requests. For approvals: “Standard/Routine requests are completed within 5 calendar days. Expedited/Urgent requests are completed within 2 calendar days.” Expedited means waiting “could place the member’s life, health, or ability to regain maximum function in serious jeopardy.” Reassessment (reauthorization) requests must “be submitted at least 10 days but not more than 30 days prior to the last day of the previously certified service”; for an authorization ending 4/30, submit no earlier than 4/1. CCP’s own MMA manual says standard requests “will not exceed 5 calendar days” and expedited “will not exceed 2 business days.” The AHCA contract sets 2 days for expedited.^[1][3][4]

CCP’s MMA manual: “Claims with primary and secondary coverage cannot be processed simultaneously. Medicaid is the payer of last resort. Submit claims to the primary payer first.” BA claims go to Therapy Network of Florida, not CCP, and TNFL allows “ninety (90) days from the date of final determination of the primary payer” for a claims complaint. Neither manual says whether a TNFL BA authorization is still needed when a commercial plan is primary. Florida Medicaid pays last. Rule 59G-1.052 says: “Florida Medicaid is the payer of last resort. Providers must exhaust all TPL sources of payment, such as Medicare, TRICARE, private health insurance … prior to submitting or resubmitting a claim.” The AHCA contract binds every MMA plan to that rule. Two consequences for intake: Medicaid pays only “the difference between the Florida Medicaid rate and the third-party payment,” and it pays nothing when “the provider’s TPL claim is denied for failing to obtain the appropriate authorization from the third-party.” So get the commercial plan’s own ABA authorization first.^[3][1][5]

Ask the plan: Therapy Network of Florida: whether a TNFL BA authorization is required when a commercial plan pays first.

CCP makes supervision visible on the schedule rather than as a ratio. The behavior plan must carry a “supervision plan, including name(s) of authorized supervisor(s), and list this in the schedule,” and the requested weekly schedule must show “days of the week, hours of the day, service codes for those hours, to include supervision” — CCP’s own worked example pairs 97153 blocks with 97155 and 97156 blocks by day. The state standard sits underneath: supervision of BCaBAs and RBTs per the Council of Autism Service Providers practice standards, as specified in the approved behavior plan.^[1][2]

CCP restates the state exclusion verbatim in its own exclusion list: “services by more than one BA provider unless determined to be medically necessary, prior authorized and indicated in the approved behavior plan.” The reimbursement half of the state rule applies too — the supervisee is not reimbursed when the supervisor is reimbursed for the same time period. So concurrency is something the approved plan and the TNFL authorization have to carry explicitly; the requested schedule is where it gets declared.^[1][2]

By the week, with a documentation trigger. The state ceiling of up to 40 hours per week as prior-authorized in the behavior plan applies, and CCP’s documentation tips flag “any requests for more than 40 hours” as needing support. “Services not on the Florida BA fee schedule are non-covered,” and members 21 and over are excluded outright. No per-code per-day unit ceiling is published.^[1][2]

Ask the plan: Therapy Network of Florida for any per-day claim edit, and the current AHCA BA fee schedule for per-assessment unit caps.

CCP publishes three signature rules, and this is the tightest-documented set among Florida’s nine plans. Session notes: “the notes must be signed and dated by the rendering practitioner,” carrying date, time, location and duration, maladaptive behaviors observed, replacement/compensatory skills targeted, the recipient’s response, protocol modification or therapist direction, an explanation if the parent or guardian was not present, and the participants. Plan: “the behavior assessment and behavior plan must be signed by the Lead Analyst and the recipient’s parent or caregiver.” And every signature on the treatment-plan document “must include their NPI, credentials and date of signature as defined in Chapter 668, Part I, F.S.”^[1][2]

School is gated, and CCP asks for the detail up front: the full behavior assessment must include “detailed information about the school name, time frame, classroom type, IEP recommendation, 504 plan and services,” and an authorization request for services delivered in a school must include the IEP — failing which, documentation justifying the services plus an estimated IEP timeframe, a 504 plan if the school does not conduct IEPs, or the school’s name with an explanation if it conducts neither. The behavior plan must also name the treatment setting. CCP’s exclusion list goes one item beyond the state’s: personal care assistance, companion, chaperone or shadow; caregiver or childcare; travel time; and “services in PPEC.”^[1][2]

Everything goes to Therapy Network of Florida, not to Community Care Plan — “do not send any claims to the health plans,” and a payment made in error by the plan is an overpayment to be returned. TNFL’s payer ID is 65062 for professional claims and 12k89 for institutional; paper claims go on an original CMS-1500 (or UB-04 for institutionally billed claims) to the TNFL claims processing centre in Ft. Lauderdale. A claim submitted before the authorization is approved “will deny for no authorization.” Adjustment requests run 365 days from the EOP/EOB date. Underneath, the state enrollment structure still decides whose NPI may render: Lead Analyst 392, BCaBA 391, RBT 390, inside an enrolled BA group (393).^[1][2]