Clinical Policy - Behavior Analysis Services - Reference Number FL.CP.BH.500

Q: Who qualifies for medically necessary behavior analysis (BA) services under this policy?

Members or enrollees must be under 21 years of age and present behavior concerns that contribute to functional impairment in specified domains such as safety, communication, self-stimulation, self-care, or other relevant behaviors.

Q: What evaluations and documentation are required before BA services can be authorized?

Authorization requires comprehensive diagnostic evaluation (CDE) following national evidence-based standards and a behavior assessment conducted prior to service initiation, including clinical interviews, history review, and standardized assessment instruments.

Q: What must be included when initiating BA treatment services?

Initiation requires the prior behavior assessment, a behavior plan with defined measurable goals, baseline and observation procedures, mastery and generalization criteria, progress reporting expectations, parent/caregiver training elements, and justification for requested billing unit counts plus a supervision and care coordination plan.

Sep 20, 2026

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Clinical policy defines Sunshine Health’s utilization management requirements for prior authorization of behavior analysis (BA) services. It describes when BA services are considered medically necessary for members under 21, including behavior concerns across safety, communication, self-stimulation, self-care, and other related functional impairment domains. The policy specifies required documentation for authorization decisions, including comprehensive diagnostic evaluation, behavior assessment prior to service initiation, mandated testing tools, and treatment initiation criteria.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages9

Reading Time23 min

AccessFree to download

Policy/Criteria

Medical Necessity Conditions

Required Documentation and Evaluation Components

Treatment Initiation Requirements

Clinical Policy: Behavior Analysis Services Reference Number: FL.CP.BH.500 Date of Last Revision: 06/24 See Important Reminder at the end of this policy for important regulatory and legal information. Description This clinical policy outlines the utilization management of authorization requests for behavior analysis services within Sunshine Health based off Florida Agency for Health Care Administration behavior analysis services coverage policy1, authorized by section 409 .906, Florida Statutes (F. S.)2, and deemed medically necessary as defined in Rule 59G-1 .010, F.A.C.3 Behavior analysis (BA) services are highly structured interventions, strategies, and approaches provided to decrease maladaptive behaviors and increase or reinforce appropriate behaviors.1 Required documentation and materials for determining prior authorization are stored and maintained in Sunshine Health’s Health Insurance Portability and Accountability (HIPPA) Compliant EMR System. Policy/Criteria I. It is the policy of Sunshine Health Plan and Centene Advanced Behavioral Health that behavior analysis (BA) services are medically necessary when meeting all of the following: A. Member/Enrollee is <21 years of age; B. Member/Enrollee presents with behavior concerns, contributing to functional impairment in any of the following areas: 1. Safety, any of the following: a. Aggression; b. Self-injury; c. Property destruction; d. Elopement; 2. Communication, any of the following: a. Problems with expressive/receptive language; b. Poor understanding or use of non-verbal communications; c. Stereotyped; d. Repetitive language; 3. Self-stimulation, any of the following: a. Abnormal; b. Inflexible; c. Intense preoccupations; 4. Self-care, any of the following: a. Difficulty recognizing risks or danger; b. Grooming; c. Eating, d. Toileting; 5. Other behaviors not identified but not limited to complexity of treatment, programming, or environmental variables; C. Referred by an independent physician or practitioner qualified to assess and diagnose disorders related to functional impairment, including one of the following: 1. Primary care physician with family practice, internal medicine, or pediatrics specialty; 2. Board certified or board eligible physician with specialty in one of the following: a. Developmental behavioral pediatrics; b. Neurodevelopmental pediatrics; c. Pediatric neurology; d. Adult or child psychiatry; 3. Child psychologist; D. Comprehensive diagnostic evaluation (CDE), performed according to national evidencebased practice standards by a multidisciplinary team or individual practitioner who is supervised by a licensed practitioner working within their scope of practice, includes all of the following: 1. Assessment findings and treatment recommendations appropriate to the member/enrollee; 2. Data from behavioral reports by parents, guardians, and/or teachers; 3. Diagnostic testing using tools including any of the following: a. Autism Diagnostic Observation Schedule (ADOS-2); b. The Childhood Autism Rating Scale – 2nd edition (CARS2); c. Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R); d. Communication and Symbolic Behavior Scales (CSBS); e. Autism Diagnostic Interview, Revised (ADI-R); f. Social Communication Questionnaire; g. Battelle Developmental Inventory– 2nd edition; 4. Hearing, and/or vision test; 5. Genetic testing; 6. Other neurological and/or medical testing; E. Behavior assessment, conducted prior to the initiations of services, includes all of the following: 1. Member/enrollee information; 2. Reason for referral; 3. Medical and developmental history, including medications prescribed to ameliorate behaviors; 4. Relevant family history; 5. Clinical interview; 6. Review of recent assessments/reports; 7. Administration, scoring, and reporting (to include outcome measures) of any assessments noted in I.D., using

FAQs

Who qualifies for medically necessary behavior analysis (BA) services under this policy?

Members or enrollees must be under 21 years of age and present behavior concerns that contribute to functional impairment in specified domains such as safety, communication, self-stimulation, self-care, or other relevant behaviors.

What evaluations and documentation are required before BA services can be authorized?

Authorization requires comprehensive diagnostic evaluation (CDE) following national evidence-based standards and a behavior assessment conducted prior to service initiation, including clinical interviews, history review, and standardized assessment instruments.

What must be included when initiating BA treatment services?

Initiation requires the prior behavior assessment, a behavior plan with defined measurable goals, baseline and observation procedures, mastery and generalization criteria, progress reporting expectations, parent/caregiver training elements, and justification for requested billing unit counts plus a supervision and care coordination plan.

Sep 20, 2026

Upload by Franzy