---
title: Simply Healthcare ABA / Behavior Analysis coverage (Florida MMA plan).
url: "https://carelu.com/payers/simply-healthcare-florida"
markdown_url: "https://carelu.com/payers/simply-healthcare-florida.md"
state: FL (Florida)
payer: Simply Healthcare Plans (FL)
kind: Medicaid managed care plan (MCO)
parent_program: Florida Medicaid (AHCA)
description: "How Simply Healthcare (Elevance) administers Florida Medicaid Behavior Analysis — full delegation to Carelon Behavioral Health for both authorizations and claims, the 30-day treatment-plan freshness rule, eServices and Availity workflows."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Simply Healthcare ABA / Behavior Analysis coverage (Florida MMA plan).

_Payer Guide · Simply Healthcare (FL) · Last updated September 2026 · 2 primary sources_

> BA fully delegated to Carelon — auths AND claims; 30-day data-freshness rule on PAs.

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.

This plan administers the **Florida Medicaid (AHCA)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Florida Medicaid — Behavior Analysis Services (AHCA) guide](https://carelu.com/payers/florida-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — via Carelon Behavioral Health: eServices portal or fax 1-800-370-1116 [1]
- **Prior auth for treatment**: Required — via Carelon; treatment plan and data must be no older than 30 days at submission [1]
- **Autism diagnosis required?**: No — state BA policy applies: physician referral + order + CDE, no autism-diagnosis requirement [1][2]

## At a glance

- **Plan type:** SMMC MMA plan (Elevance Health)
- **Clinical rules:** AHCA BA Coverage Policy; UM delegated to Carelon (eff. 2/1/2025)
- **Prior auth:** Required — Carelon eServices portal or fax 1-800-370-1116
- **Freshness rule:** Treatment plan + data no older than 30 days at submission
- **Claims:** To Carelon via Availity Essentials (not Simply); Payspan for payments
- **Provider relations:** FL-dedicated Carelon team — provider.relations.FL@carelon.com

## The Carelon delegation: auths and claims

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]

## The 30-day freshness rule

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]

## Intake gates

The questions that decide whether a family can start with Simply Healthcare Plans (FL), and what they have to bring.

- **Age limit**: 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]
- **Diagnosis recency**: 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]
- **Who may diagnose**: 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.
- **Diagnostic tools required**: 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]
- **Referral required?**: 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]
- **Telehealth**: 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.
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: 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.

## Delivery and billing rules

Coverage decides whether Simply Healthcare Plans (FL) pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: 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]
- **Concurrent billing (97153 + 97155)**: 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.
- **Daily limits / MUEs**: 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.
- **Session-note signature**: 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]
- **Place of service**: 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]
- **Bill as provider**: 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]

## What intake should collect for Simply Healthcare Plans (FL)

- **Carelon setup status:** eServices for auths, Availity for claims, Payspan for payments — three registrations before the first Simply member.
- **Referral + order + CDE:** The state eligibility gate applies; no autism diagnosis required.
- **Plan/data dates:** Treatment plan and data must be under 30 days old at submission — track document dates in the packet.
- **Vineland-3 & BASC-3 scoring reports:** The state documentation stack rides along with every Carelon request.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How Simply Healthcare Plans (FL) ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00665
- **Payer ID (Availity):** SMPLY
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** Carelon Behavioral Health
- **ABA rides on:** behavioral health benefit
- **Two-hop verification required:** Yes

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required | 24 units per initial behavior assessment (max); the reassessment variant, billed with modifier TS, caps at 18 units — same $19.05/unit rate either way. per per assessment/reassessment (not daily) — a new authorization is required each time, not a recurring daily allotment. | home (categorical — no CMS POS-code number published anywhere in FL BA documentation, state or plan level), office/clinic (categorical), school (categorical — IEP/504 plan, or a documented explanation, required with the PA request per the coverage policy §7.2), community/other (categorical, per plan PA-form checkboxes) | No — not authorized for this code under the AHCA BA Coverage Policy. Only 97156 (family/caregiver training) has a stated telehealth allowance in Florida Medicaid BA; every other code is telehealth:'No' by policy design, not by omission. | TS — reassessment variant, same $19.05 rate, separate 18-unit cap (vs. 24 for the initial assessment) |
| 97152 | Yes | Required | 8 units per assessment (max). per per assessment (not daily). | home (categorical — no CMS POS-code number published anywhere in FL BA documentation, state or plan level), office/clinic (categorical), school (categorical — IEP/504 plan, or a documented explanation, required with the PA request per the coverage policy §7.2), community/other (categorical, per plan PA-form checkboxes) | No — not authorized for this code under the AHCA BA Coverage Policy. Only 97156 (family/caregiver training) has a stated telehealth allowance in Florida Medicaid BA; every other code is telehealth:'No' by policy design, not by omission. | — |
| 97153 | Yes | Required | No code-specific unit cap on the fee schedule; counts toward the aggregate 40 hrs/week (≈160 units/week) BA-intervention cap set by the coverage policy §4.2.2. per week (aggregate across all treatment codes together, not per-code). | home (categorical — no CMS POS-code number published anywhere in FL BA documentation, state or plan level), office/clinic (categorical), school (categorical — IEP/504 plan, or a documented explanation, required with the PA request per the coverage policy §7.2), community/other (categorical, per plan PA-form checkboxes) | No — not authorized for this code under the AHCA BA Coverage Policy. Only 97156 (family/caregiver training) has a stated telehealth allowance in Florida Medicaid BA; every other code is telehealth:'No' by policy design, not by omission. | XP — concurrent-supervision supervisee line, not separately reimbursed (the supervisor bills 97153/97155/97155-HN instead) |
| 97154 | Yes | Required | Max 6 participants per group (coverage policy §4.2.2); the group also counts toward the aggregate 40 hrs/week cap. Rendered by Lead Analyst, BCaBA, or RBT. per week (aggregate) plus a 6-participant group-size ceiling. | home (categorical — no CMS POS-code number published anywhere in FL BA documentation, state or plan level), office/clinic (categorical), school (categorical — IEP/504 plan, or a documented explanation, required with the PA request per the coverage policy §7.2), community/other (categorical, per plan PA-form checkboxes) | No — not authorized for this code under the AHCA BA Coverage Policy. Only 97156 (family/caregiver training) has a stated telehealth allowance in Florida Medicaid BA; every other code is telehealth:'No' by policy design, not by omission. | UN (2 clients, $7.58/unit), UP (3 clients, $7.08/unit), UQ (4 clients, $6.58/unit), UR (5 clients, $6.08/unit), US (6 clients, $5.58/unit) |
| 97155 | Yes | Required | No code-specific unit cap on the fee schedule; counts toward the aggregate 40 hrs/week cap. per week (aggregate across all treatment codes). | home (categorical — no CMS POS-code number published anywhere in FL BA documentation, state or plan level), office/clinic (categorical), school (categorical — IEP/504 plan, or a documented explanation, required with the PA request per the coverage policy §7.2), community/other (categorical, per plan PA-form checkboxes) | No — not authorized for this code under the AHCA BA Coverage Policy. Only 97156 (family/caregiver training) has a stated telehealth allowance in Florida Medicaid BA; every other code is telehealth:'No' by policy design, not by omission. | HN — BCaBA tier, $15.37/unit (vs. $19.17 Lead Analyst base rate), XP — concurrent-supervision supervisee line, not separately reimbursed |
| 97156 | Yes | Required | No code-specific cap on direct/in-person units; the TELEHEALTH variant (GT modifier) is separately capped at 2 hrs/week (8 units/week). per week (telehealth portion); aggregate 40 hrs/week cap governs the rest. | home (categorical — no CMS POS-code number published anywhere in FL BA documentation, state or plan level), office/clinic (categorical), school (categorical — IEP/504 plan, or a documented explanation, required with the PA request per the coverage policy §7.2), community/other (categorical, per plan PA-form checkboxes) | Yes — the ONLY Florida Medicaid BA code with a confirmed telehealth allowance. GT modifier, up to 2 hrs/week, per Rule 59G-1.057, F.A.C. (coverage policy §4.2.2, FL.CP.BH.500). Not confirmed whether the telehealth allowance extends to BCaBA-rendered (HN-modifier) training — both the coverage policy and Sunshine's clinical policy name the "Lead Analyst" specifically. Separately: Sunshine's general (non-BA) telehealth billing notice instructs POS 02 with NO GT/95/CR modifier appended, which appears to conflict with the BA-specific GT-modifier requirement — an unresolved discrepancy, flagged rather than guessed at; confirm the correct billing combination with each plan before submitting a 97156 telehealth claim. | GT — telemedicine delivery, same $19.05 rate, capped at 2 hrs/wk, HN — BCaBA tier, $15.24/unit (vs. $19.05 Lead Analyst base rate) |
| 97157 | No — absent from both the 2025 and 2026 AHCA Behavior Analysis fee schedules and not listed among the covered service categories in the Dec 2024 coverage policy §4.2.2. Cross-confirmed absent from Sunshine Health's own coding table (FL.CP.BH.500) and Humana's Florida Medicaid PA list too — three independent primary sources agree on the omission. This is NOT a formal written exclusion statement (no document states "97157 is excluded"), so treat this as verified-absent-from-the-billable-set rather than a proven-impossible claim. | N/A — not on the state's billable BA code set per the fee schedule and PA lists reviewed. | N/A per N/A | — | N/A | — |
| 97158 | Yes | Required | Max 6 participants per group; rendered by Lead Analyst or BCaBA only (NOT RBT, per the coverage policy — contrast 97154, which RBTs can render). per week (aggregate) plus a 6-participant group-size ceiling. | home (categorical — no CMS POS-code number published anywhere in FL BA documentation, state or plan level), office/clinic (categorical), school (categorical — IEP/504 plan, or a documented explanation, required with the PA request per the coverage policy §7.2), community/other (categorical, per plan PA-form checkboxes) | No — not authorized for this code under the AHCA BA Coverage Policy. Only 97156 (family/caregiver training) has a stated telehealth allowance in Florida Medicaid BA; every other code is telehealth:'No' by policy design, not by omission. | UN (2 clients, $9.58/unit), UP (3 clients, $9.08/unit), UQ (4 clients, $8.58/unit), UR (5 clients, $8.08/unit), US (6 clients, $7.58/unit) |
| 0362T | Yes | Required, and conditioned on medical necessity for the extra-technician protocol per the coverage policy. | 16 units per initial assessment or reassessment (max). per per assessment/reassessment. | home (categorical — no CMS POS-code number published anywhere in FL BA documentation, state or plan level), office/clinic (categorical), school (categorical — IEP/504 plan, or a documented explanation, required with the PA request per the coverage policy §7.2), community/other (categorical, per plan PA-form checkboxes) | No — not authorized for this code under the AHCA BA Coverage Policy. Only 97156 (family/caregiver training) has a stated telehealth allowance in Florida Medicaid BA; every other code is telehealth:'No' by policy design, not by omission. | — |
| 0373T | Yes | Required, and conditioned on medical necessity for the extra-technician protocol. | No distinct unit cap beyond the underlying code's session limits — the fee schedule doesn't publish one separately for this add-on. | home (categorical — no CMS POS-code number published anywhere in FL BA documentation, state or plan level), office/clinic (categorical), school (categorical — IEP/504 plan, or a documented explanation, required with the PA request per the coverage policy §7.2), community/other (categorical, per plan PA-form checkboxes) | No — not authorized for this code under the AHCA BA Coverage Policy. Only 97156 (family/caregiver training) has a stated telehealth allowance in Florida Medicaid BA; every other code is telehealth:'No' by policy design, not by omission. | — |

Code notes:

- **97151:** Physician referral + order + Comprehensive Diagnostic Evaluation gate the very first assessment request (no autism-diagnosis requirement) — see the guide's prose for the intake sequence. Carelon requires the treatment plan and supporting data to be no older than 30 days at PA submission (a process rule layered on top of the state's 6-month clinical reassessment cycle) — refresh data collection before assembling any renewal packet. These are the statewide AHCA BA Coverage Policy mechanics, binding on Carelon Behavioral Health (Simply Healthcare) per the policy's plan-compliance clause (§1.2); Carelon Behavioral Health (Simply Healthcare)'s own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Carelon Behavioral Health (Simply Healthcare) provider relations before quoting a family.
- **97152, 97156, 97158:** Carelon requires the treatment plan and supporting data to be no older than 30 days at PA submission (a process rule layered on top of the state's 6-month clinical reassessment cycle) — refresh data collection before assembling any renewal packet. These are the statewide AHCA BA Coverage Policy mechanics, binding on Carelon Behavioral Health (Simply Healthcare) per the policy's plan-compliance clause (§1.2); Carelon Behavioral Health (Simply Healthcare)'s own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Carelon Behavioral Health (Simply Healthcare) provider relations before quoting a family.
- **97153:** Billed at the SAME $12.26/unit rate whether rendered by an RBT, BCaBA, or Lead Analyst — Florida does not tier 97153 by staff credential (contrast 97155/97156, which do via the HN modifier). Carelon requires the treatment plan and supporting data to be no older than 30 days at PA submission (a process rule layered on top of the state's 6-month clinical reassessment cycle) — refresh data collection before assembling any renewal packet. These are the statewide AHCA BA Coverage Policy mechanics, binding on Carelon Behavioral Health (Simply Healthcare) per the policy's plan-compliance clause (§1.2); Carelon Behavioral Health (Simply Healthcare)'s own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Carelon Behavioral Health (Simply Healthcare) provider relations before quoting a family.
- **97154:** The modifier documents group size, not staff credential — rate scales DOWN as the group grows. Carelon requires the treatment plan and supporting data to be no older than 30 days at PA submission (a process rule layered on top of the state's 6-month clinical reassessment cycle) — refresh data collection before assembling any renewal packet. These are the statewide AHCA BA Coverage Policy mechanics, binding on Carelon Behavioral Health (Simply Healthcare) per the policy's plan-compliance clause (§1.2); Carelon Behavioral Health (Simply Healthcare)'s own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Carelon Behavioral Health (Simply Healthcare) provider relations before quoting a family.
- **97155:** Rendered by Lead Analyst or BCaBA only — RBTs do not bill 97155 in Florida. Carelon requires the treatment plan and supporting data to be no older than 30 days at PA submission (a process rule layered on top of the state's 6-month clinical reassessment cycle) — refresh data collection before assembling any renewal packet. These are the statewide AHCA BA Coverage Policy mechanics, binding on Carelon Behavioral Health (Simply Healthcare) per the policy's plan-compliance clause (§1.2); Carelon Behavioral Health (Simply Healthcare)'s own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Carelon Behavioral Health (Simply Healthcare) provider relations before quoting a family.
- **97157:** If a family reports a Florida plan authorizing/paying 97157, verify directly with that plan — it would be an accommodation outside the state fee schedule, not the documented default. These are the statewide AHCA BA Coverage Policy mechanics, binding on Carelon Behavioral Health (Simply Healthcare) per the policy's plan-compliance clause (§1.2); Carelon Behavioral Health (Simply Healthcare)'s own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Carelon Behavioral Health (Simply Healthcare) provider relations before quoting a family.
- **0362T:** Requires an on-site physician/QHP plus 2+ technicians for severe/destructive-behavior assessment support; billed alongside 97151/97151-TS, not standalone. Carelon requires the treatment plan and supporting data to be no older than 30 days at PA submission (a process rule layered on top of the state's 6-month clinical reassessment cycle) — refresh data collection before assembling any renewal packet. These are the statewide AHCA BA Coverage Policy mechanics, binding on Carelon Behavioral Health (Simply Healthcare) per the policy's plan-compliance clause (§1.2); Carelon Behavioral Health (Simply Healthcare)'s own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Carelon Behavioral Health (Simply Healthcare) provider relations before quoting a family.
- **0373T:** Requires an on-site physician/QHP plus 2+ technicians for severe/destructive-behavior exposure treatment; billed alongside 97153/97155. Carelon requires the treatment plan and supporting data to be no older than 30 days at PA submission (a process rule layered on top of the state's 6-month clinical reassessment cycle) — refresh data collection before assembling any renewal packet. These are the statewide AHCA BA Coverage Policy mechanics, binding on Carelon Behavioral Health (Simply Healthcare) per the policy's plan-compliance clause (§1.2); Carelon Behavioral Health (Simply Healthcare)'s own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Carelon Behavioral Health (Simply Healthcare) provider relations before quoting a family.

### Contacts

- **Provider services phone:** 1-800-397-1630
- **Hours:** Carelon National Provider Service Line: Monday–Friday, 8 a.m.–8 p.m. Eastern. (Availity Client Services, a separate line, keeps the same hours: 1-800-282-4548.)
- **Portal:** [Availity Essentials (claims); Carelon eServices (authorizations)](https://www.availity.com/)
- **Fax:** 1-800-370-1116

Questions to ask on a verification call:

- What payer ID should we use for Change Healthcare eligibility checks, and do you support real-time 270/271?
- What EDI payer ID does Carelon Behavioral Health use for Simply ABA claims/authorizations — is it separate from Simply’s own SMPLY ID?
- Which service-type code do you return ABA benefit details under?
- Does the deductible apply to ABA services, and is the cost share a copay or coinsurance?
- Is any copay charged per visit or per day, and does the out-of-pocket max apply to ABA?
- What’s the cap period for 0373T?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/06/pVeify-Payer-List-June-26.pdf (accessed 2026-07-23)
- https://provider.simplyhealthcareplans.com/florida-provider/electronic-data-interchange (accessed 2026-07-23)
- https://provider.simplyhealthcareplans.com/docs/gpp/FLFL_SIMPLY_CarelonBehavioralAnalysisTrainingRes.pdf?v=202503041513 (accessed 2026-07-23)
- https://www.carelonbehavioralhealth.com/content/dam/digital/carelon/cbh-assets/documents/global/carelon-behavioral-health-provider-handbook.pdf (accessed 2026-07-23)
- https://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/COMPANION%20GUIDES/FMMIS_5010_270_271_Companion%20Guide_v4_0_04272023.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.flrules.org/gateway/readRefFile.asp?refId=17525&filename=Florida%20Medicaid%20Behavior%20Analysis%20Services%20Coverage%20Policy.pdf (accessed 2026-07-23)
- https://ahca.myflorida.com/content/download/26138/file/2025%20Behavior%20Analysis%20Fee%20Schedule.pdf (accessed 2026-07-23)
- https://www.carelonbehavioralhealth.com/content/dam/digital/carelon/cbh-assets/documents/global/clinical/aba-authorization-request-form-2019-cpt-codes.pdf (accessed 2026-07-23; source document older than 18 months)

## Common questions

### Does Simply Healthcare cover ABA in Florida?

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.

### Where do Simply Healthcare ABA authorizations go?

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.

### What is the 30-day rule on Simply/Carelon PAs?

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.

## Primary sources

1. [Simply Healthcare / Carelon — Behavioral Analysis provider training (Feb 2025)](https://provider.simplyhealthcareplans.com/docs/gpp/FLFL_SIMPLY_CarelonBehavioralAnalysisTrainingRes.pdf?v=202503041513)
2. [Florida Medicaid BA Services Coverage Policy (Dec 2024)](https://www.flrules.org/gateway/readRefFile.asp?refId=17525&filename=Florida%20Medicaid%20Behavior%20Analysis%20Services%20Coverage%20Policy.pdf)
3. [Simply Healthcare — Florida SMMC MMA and Florida Healthy Kids Provider Manual (Nov 2025)](https://provider.simplyhealthcareplans.com/docs/gpp/FLFL_SMH_FHKProviderManual.pdf?v=202606181620)
4. [AHCA SMMC Model Health Plan Contract — Attachment II Core Provisions (update 10/1/2025), §V.6 and §XI.D](https://ahca.myflorida.com/content/download/27248/file/Attachment%20II-%20-%20Core%20Contract%20Provisions%20Oct%202025.pdf)
5. [Rule 59G-1.052, F.A.C. — Third-Party Liability Requirements (AHCA)](https://ahca.myflorida.com/content/download/5929/file/59G_1052_TPL_Requirements.pdf?version=1)

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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.