Humana Healthy Horizons in Florida ABA / BA coverage (MMA plan).

Follows the Florida Medicaid rule: BA is for recipients under the age of 21, with EPSDT available above the coverage-policy and fee-schedule limits. Humana’s BA informational flyer and ABA toolkit publish no plan-specific age limit, and the state policy forbids a plan from applying more stringent service coverage limits.^[4][1]

No autism diagnosis is required. Humana’s own instrument clock tracks the state cycle: the BASC-3 PRQ is required for ages 2 through 18 at the initial request and every 12 months, on top of the state’s reassessment and updated behavior plan at least every six months. The Comprehensive Diagnostic Evaluation itself carries no published expiry.^[1][4]

The state rule, restated in Humana’s documentation list: the physician’s order and the Comprehensive Diagnostic Evaluation both attach to the request, with the referral coming from an independent physician or qualifying practitioner and the CDE led by a licensed practitioner working within their medical, developmental or psychological scope of practice. Humana publishes no narrower list of its own.^[1][4]

Humana names the BASC-3 PRQ explicitly — ages 2 through 18, at the initial request and every 12 months — as a required attachment alongside the CDE and the physician’s order. The state pair applies in full, so the Vineland-3 Comprehensive Parent Interview Form (plus the Maladaptive Behavior Domain for ages 3 and older) rides with it, complete scoring reports included.^[1][4]

Required, and Humana publishes the fullest documentation list of the nine plans: the Comprehensive Diagnostic Evaluation, the physician’s order, the BASC-3 PRQ, a rationale for the requested hours, and the IEP or 504 plan when services are school-based — submitted on the Florida ABA PA form (MCD 466) through Availity Essentials (preferred), the 24/7 IVR at 800-523-0023, or fax 813-321-7220. Humana’s current flyer adds that “the Behavior Analysis Authorization form should be completed and included with your authorization request” and that “a valid Medicaid ID is required for all providers, whether located in Florida or out of state, as a condition of payment.”^[1][2][4]

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. Humana’s BA informational flyer and ABA toolkit publish no telehealth code list, modifier set or place-of-service rule for Florida BA.^[4][1]

Ask the plan: Humana’s Florida BA mailbox (FLBA@humana.com) or the provider line 800-477-6931 before scheduling a remote session other than 97156 caregiver training.

Humana’s 2026 Florida provider handbook publishes no decision timeframe for PA requests. Its PA page says only that requests “should be made as soon as possible.” The contract clock therefore applies. The AHCA contract every MMA plan signs sets the clock: plans “shall provide standard authorization decisions within no more than five (5) days following receipt of the request for service,” extendable by “up to four (4) additional days,” and expedited decisions “no later than two (2) days after receipt,” extendable by one day. The contract defines days as calendar days. That is stricter than the federal Medicaid managed-care cap (7 calendar days standard and 72 hours expedited for rating periods from 1/1/2026, 42 CFR 438.210(d)), so the state clock governs. Humana’s BA request must include a current assessment “from within the past 60 days,” so time the reassessment to the submission. No reauthorization lead time is published.^[5][6][7]

Humana’s handbook says only: “Humana Healthy Horizons assumes full responsibility for collections in the event of third-party liability.” It publishes no step-by-step rule on billing the other payer first. The state rule that binds every MMA plan still applies. 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.^[5][8][7]

Ask the plan: Humana Provider Services (IVR 800-523-0023): whether Humana wants the commercial EOB before its claim, and whether its BA authorization is still required when a commercial plan pays first.

The state floor: supervision of BCaBAs and RBTs per the Council of Autism Service Providers practice standards, specified in the supervision plan inside the approved behavior plan, which names the authorized supervisors. Humana adds no ratio or caseload cap — but it does ask for a rationale for the requested hours with every authorization, which is where a supervision schedule has to be justified.^[4][1]

The state rule governs and Humana publishes no variation: the supervisee is not reimbursed when the supervisor is reimbursed for the same time period, and simultaneous services by more than one BA provider are non-covered unless medically necessary, prior authorized and indicated in the approved behavior plan.^[4]

Ask the plan: Humana’s Florida BA mailbox (FLBA@humana.com) or the named regional BA representative for whether an authorization may carry 97153 and 97155 on the same clock time.

The state weekly ceiling of up to 40 hours per week of BA intervention as prior-authorized in the behavior plan, with EPSDT available above it and group treatment capped at six participants. Humana bills “reimbursement for all services in 15-minute increments” and requires add-on codes to be billed with the corresponding base code. No per-day unit table is published.^[4][1]

Ask the plan: Humana provider services (800-477-6931) for per-day claim edits; the AHCA fee schedule under Rule 59G-4.002 for per-assessment unit caps.

The state rule: session notes signed and dated by the rendering practitioner, carrying date, time, location, duration, behaviors observed, skills targeted, the recipient’s response, protocol modification or therapist direction, an explanation if the parent or guardian was absent, and the participants; the behavior assessment and behavior plan signed by the Lead Analyst and the parent or guardian. Humana publishes no additional signature rule for BA.^[4][1]

Humana makes the state school rule an explicit line item on its documentation list — the IEP or 504 plan is required when services are school-based — and the state rule supplies the rest: in the absence of an IEP, documentation justifying the services plus an estimated IEP timeframe; 1:1 shadow, personal care, companion and chaperone services non-covered regardless of setting; travel time non-covered.^[1][4]

Humana publishes the box-by-box rule: “use the CMS-1500 form to submit claims for behavioral analysis services”; if the rendering provider is in a group and the group is being paid, “the group will be captured in the billing provider section (Box 33), and then the rendering provider will be captured in the rendering provider section (Box 24)”; if the rendering provider is the one being reimbursed, they go in Box 33; and “enter the individual rendering (treating) provider’s number in Item 24 J… only when it is different from the pay-to provider number.” Claims go out under payer ID 61101 through Availity (paper to the Lexington, KY claims office), clean claims process within 20 days, and for codes inside an approved authorization non-participating providers default to the lesser of the amount Humana specified on the authorization form or 100% of the applicable Medicaid fee schedule.^[1][4]