Simply Healthcare, Elevance's Florida plan, took the most distinctive path of the nine MMA plans at the February 1, 2025 carve-in: it delegated Behavior Analysis UM to Carelon Behavioral Health — and not just authorizations. Claims go to Carelon too, via Availity Essentials, making Simply the only Florida plan where providers effectively work for a national behavioral-health vendor end to end. Clinical criteria still defer to the AHCA policy; the workflow is what's different, including one Carelon-specific rule with real intake consequences: treatment plans and data must be no older than 30 days when the PA is submitted.
Effective February 1, 2025, Simply's BA authorizations run through Carelon Behavioral Health — submit via the Carelon eServices portal or fax 1-800-370-1116 — and claims submit to Carelon through Availity Essentials (Carelon's preferred direct-data-entry channel), with Payspan handling payments. At the transition, existing authorizations were auto-extended at least 90 days for continuity of care. Support runs through Carelon's National Provider Service Line, Availity Client Services, and a Florida-dedicated provider-relations mailbox at provider.relations.FL@carelon.com. For a practice used to billing the health plan directly, the operational takeaway is blunt: for Simply members, your counterparty is Carelon — portal registrations, claims setup, and escalation paths should all be built there.[1]
Carelon requires that the treatment plan and supporting data be no older than 30 days at the time of PA submission. That's a process rule, not a coverage limit — the state's 6-month reassessment cycle still governs clinically — but it changes sequencing: don't finalize the behavior plan months ahead of the submission date, and when a renewal window opens, refresh data collection before assembling the packet. A stale-dated plan is an avoidable administrative denial. Everything else follows the state stack: referral + order + CDE at entry, Vineland-3/BASC-3 scoring reports, up-to-6-month authorization periods.[1]
The questions that decide whether a family can start with Simply Healthcare Plans (FL), and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the Florida Medicaid rule: BA is for recipients under the age of 21. Carelon’s February 2025 behavioral analysis training for Simply publishes no age criterion of its own, and the coverage policy bars a plan from applying more stringent service coverage limits than state policy.[2][1]
No autism diagnosis is required, but Carelon imposes the tightest freshness rule of the nine Florida plans: the treatment plan and supporting data “should be no older than 30 days at the time of submission,” and “the plan should contain current Vineland and BASC scores.” That is a process rule sitting on top of the state’s clinical cycle — reassessment and an updated behavior plan at least every six months, core instruments re-administered every 12 — and it changes sequencing: refresh data collection before assembling a renewal packet rather than finalising the plan months ahead.[1][2]
Carelon narrows the CDE author in its own training material: “CDE: diagnostic evaluation completed by a medical doctor specializing in developmental behavioral pediatrics, neurodevelopmental pediatrics, pediatric neurology, adult or child psychiatry, or a child psychologist,” and the evaluation must be “signed by the qualified diagnostician.” Note what is missing against the state list — the primary care physician in family practice, internal medicine or pediatrics. Because the coverage policy forbids a plan from being more stringent than Florida Medicaid policy, a PCP-authored CDE should still be acceptable, but Carelon’s published packet does not say so.[1][2]
Ask the plan: Carelon (eServices, or provider.relations.FL@carelon.com) on whether a PCP-authored CDE is accepted for a Simply member — the state list is wider than Carelon’s published one.
The state pair, with a currency requirement: Carelon requires the submitted treatment plan to “contain current Vineland and BASC scores,” which in the state policy means the Vineland-3 Comprehensive Parent Interview Form (plus the Maladaptive Behavior Domain for ages 3 and older) and the BASC-3 PRQ for ages 2 through 18, with complete scoring reports attached to the prior-authorization request and re-administration every 12 months.[1][2]
Required. Carelon’s submission checklist is explicit: “a referral for BA therapy by a qualified diagnostician,” with the CDE attached and signed by that diagnostician; an up-to-date treatment plan with member-specific information and data; the completed request form; and the IEP or 504 plan if applicable. The state requirement that the referral include a physician’s order for BA services applies underneath.[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. Carelon’s February 2025 BA training for Simply publishes no telehealth rule of its own — no code list, no place-of-service guidance and no expansion beyond the state provision.[2][1]
Ask the plan: Carelon eServices or provider.relations.FL@carelon.com before scheduling any remote session other than 97156 caregiver training.
Simply’s MMA manual publishes only the expedited clock: “Decisions on urgent requests (that is, expedited service authorizations) will be made within two calendar days,” and expedited requests must go through Availity Essentials, not fax or phone. It publishes no standard-request number, so the contract clock 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. Carelon runs Simply’s BA reviews, and its 30-day rule bites first: the treatment plan and data must be no more than 30 days old when submitted. No reauthorization lead time is published.[3][4][1]
Simply’s manual: “the Medicaid program will be the payer of last resort when third-party resources are available.” When Simply knows of other coverage before paying, it will reject the claim “and redirect the provider to bill the appropriate insurance carrier,” or recover after payment if it learns later. Send COB/TPL information to Florida Claims Correspondence with a Claim Correspondence Form and the other payer’s EOP. The manual does not say whether a Simply (Carelon) 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][5][4]
Ask the plan: Carelon (1-800-397-1630), before the first date of service: whether Simply requires its own BA authorization when a commercial plan pays first.
Coverage decides whether Simply Healthcare Plans (FL) pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
The state floor, unchanged by the Carelon delegation: supervision of BCaBAs and RBTs follows the Council of Autism Service Providers practice standards as specified in the supervision plan inside the approved behavior plan, which must name the authorized supervisors. Rendering is credential-chained — Lead Analyst (BCBA, FL-CBA, or Ch. 490/491 licensee), BCaBA under a BCBA, RBT under a BCBA or BCaBA. Carelon’s BA training adds no ratio or caseload cap.[2][1]
The state rule governs and Carelon 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.[2]
Ask the plan: Carelon’s National Provider Service Line or provider.relations.FL@carelon.com for whether an authorization can carry 97153 and 97155 on the same clock time.
The state weekly ceiling: up to 40 hours per week of BA intervention as prior-authorized in the behavior plan, EPSDT available above it when medically necessary, group treatment capped at six participants, and 15-minute units on the CMS 8-minute rule. Carelon publishes no per-day unit table for Simply.[2][1]
Ask the plan: Carelon for the per-day edits its claim system applies; the current AHCA BA fee schedule for per-assessment unit caps.
The state rule: session notes are signed and dated by the rendering practitioner, carrying date, time, location, duration, behaviors observed, skills targeted, the recipient’s response, protocol modifications or therapist direction, an explanation if the parent or guardian was absent, and the participants. The behavior assessment and behavior plan carry two signatures — the Lead Analyst and the parent or guardian. Carelon layers a date discipline rather than a signature one: the plan and data must be under 30 days old when submitted, so document dates are themselves a claim risk.[2][1]
The state rule, with Carelon collecting the school evidence in its packet: the IEP or 504 plan is a listed submission item “if applicable,” and the state requires a school-based request to carry the IEP, or a 504, or documentation naming the school and explaining that neither exists. Non-covered regardless of setting: 1:1 shadow, personal care assistance, companion and chaperone services, caregiver or childcare, and travel time.[2][1]
Your counterparty is Carelon, not Simply: authorizations go to Carelon through eServices or fax 1-800-370-1116, and claims go to Carelon through Availity Essentials — its preferred direct-data-entry channel — with Payspan handling payments. The claim itself still rides on the state enrollment structure: each rendering practitioner enrolls with AHCA (Lead Analyst 392, BCaBA 391, RBT 390), with 390s and 391s enrollable only inside an enrolled BA group (393). Three registrations — eServices, Availity, Payspan — precede the first Simply member.[1][2]
Yes — on the AHCA Behavior Analysis criteria (no autism diagnosis required), with utilization management and claims both delegated to Carelon Behavioral Health since February 1, 2025.
To Carelon — via the eServices portal or fax 1-800-370-1116. Claims also go to Carelon, submitted through Availity Essentials, not to Simply directly.
The treatment plan and supporting data must be no older than 30 days at submission — a Carelon process rule layered on the state's 6-month clinical cycle. Refresh data before assembling any renewal packet.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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