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Behavior Analysis Services Information

Service Information

What is Behavior Analysis
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BA Coverage Policy
BA Fee Schedule
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Updates and Resources

Policy and Fee Schedule Frequently Asks Questions (FAQ) July 2022
Summary of Updates

Training Registration
Helpful Information and Presentations
Telemedicine during the Public Health Emergency Period
Updates to Health Care Clinic Licensure for Florida Medicaid Providers

Recipients

Information
Have a BA Question?

Providers

BA Prior Authorization Submission Requirements
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Provider Alert Archive
Have a BA Question?
Medicaid Behavior Analysis Service Provider listing

What is Behavior Analysis?

Behavior analysis (BA) services are highly structured interventions, strategies, and approaches provided to decrease maladaptive behaviors and increase or reinforce appropriate behaviors. More information, including fact sheets and videos, is located on the Behavior Analyst Certification Board’s website.

Updates to Behavior Analysis

Up-to-date information regarding Florida Medicaid behavior analysis service can be found here. Providers can also signup receive to provider alerts by registering at
https://ahca.myflorida.com/Medicaid/alerts/alerts.shtml
.

Topic Information
Behavior Analysis providers must have a National Provider Identified (NPI) All rendering, ordering, prescribing, or attending providers enrolled in Florida Medicaid must have a National Provider Identifier (NPI) on file with the Agency to comply with federal requirements.

Please see this March 4, 2022 provider alert for specific NPI information for behavior analysis providers. You can also review more recent NPI detailed information in this provider alert archive:
  • How to confirm whether you have an NPI in your file,
  • How to obtain an NPI if you do not already have one, and
  • How to update your enrollment file with your NPI

For questions, please contact Provider Enrollment 1-800-289-7799, Option 4

Fee Schedule Transition to Current Procedural Terminology (CPT) Codes

The Agency adopted the American Medical Association (AMA) Current Procedural Terminology (CPT) codes for the Florida Medicaid Behavior Analysis fee schedule, effective August 1, 2022. The current 2022 fee schedules are available on the Agency’s reimbursement schedule page, Rule 59G-4.002, Provider Reimbursement Schedules and Billing Codes. Effective August 1, 2022:
  • All authorization requests must reflect CPT codes.
  • All claims for dates of service on August 1, 2022, and thereafter must use CPT codes.

If you have questions regarding the behavior analysis prior authorization process, contact eQHealth Solutions via email at pr@eqhs.com or call 855-440-3747.

Behavior Analysis Coverage Policy The Agency is promulgating an update to the BA Services Coverage Policy.
Moratorium

The Agency temporary moratorium on enrollment of new BA group providers and individual providers practicing independent of a group in Miami-Dade and Broward counties expired November 13, 2022.

Multidisciplinary Team (MDT)

MDT Updates: Provides information to behavior analysis providers in Regions 4 and 7

The Agency directed eQHealth Solutions, Inc. to implement a multidisciplinary team approach to reviewing prior authorization requests for behavior analysis services in Regions 4 and 7, as a pilot, beginning July 1, 2019. As a part of the MDT review process, all requests for more than 20 hours per week must undergo a telephone or face-to-face staffing to ensure the child is receiving all necessary services and supports. While this approach has proven valuable in obtaining additional information about the needs of the child, the Agency has identified opportunities to streamline and expedite the process, while continuing to engage providers and parents.

The Agency has limited the circumstances in which an MDT meeting is needed, as follows:
  • If the request for BA services can be approved after completion of the desk review, the provider will be notified electronically via eQSuites, and the care coordinator will contact the parent/legal guardian to notify of the final decision.
  • If the request for BA services cannot be approved because information is missing, there are inconsistencies in the record, or the request does not meet medical necessity (in whole or part), eQHealth will schedule a peer- to-peer telephonic review with the provider in lieu of an MDT meeting. If the concerns can be resolved during the peer-to-peer review, the case will be approved.
    • If the request still cannot be approved after the peer-to-peer review, eQHealth will call the parent to discuss the decision and follow with the standard denial letter with appeal rights.
  • If eQHealth believes the child may benefit from additional services or supports, a care coordinator will contact the parent to discuss how to initiate those services. BA services will not be delayed while this is occurring.

eQHealth will only initiate MDT meetings in cases where convening treatment providers may be of benefit in maximizing the treatment outcomes, particularly where progress has stalled or regressed over several review periods.

It is of chief importance to us to solicit input from parents prior to making a service authorization decision, so eQHealth will continue to contact the child’s parent/guardian prior to completing the review to collect information and to discuss any additional needs that may have arisen.

For more information, please visit the eQHealth Training Resources page.

eQHealth Training Registration

Upcoming training opportunities for the Multidisciplinary Team (MDT) meetings are detailed below:
Topic Date and Time Link
eQHealth Solutions' Multidisciplinary Trainings Recurring Register for these trainings on eQHealth Solutions' website: http://fl.eqhs.org/ProviderResources/Registerforawebinar.aspx

Agency Training and Presentations

Subject Resource
July 29, 2022 BA Fee Schedule Training Webinar Recording
Behavior Analysis Provider Enrollment (May 2019) Presentation: Enrolling as a Florida Medicaid Behavior Analysis Provider
Webinar Recording: Enrolling as a Florida Medicaid Behavior Analysis Provider
Behavior Analysis Provider Enrollment (April 2019) Medicaid Behavior Analysis (Provider Type 39) Enrollment Webinar

Recipient Information

1. What are Behavior Analysis (BA) Services?

Behavior analysis services provide a way for a person to reduce unwanted behaviors and increase desired behaviors.  

2. Who can receive BA Services?

Florida Medicaid covers BA services for eligible Florida Medicaid recipients under the age of 21 years requiring medically necessary BA services. BA services for eligible individuals 21 years and older are available through the iBudget Waiver.

3. Who is eQHealth?

eQHealth Solutions is the company that reviews all requests for BA services covered under Florida Medicaid. A BA provider will submit the service request to eQHealth, which will review the service need based on medical necessity. After the determination is made, eQHealth will send you a letter.

4. How do I find a provider?

A link to BA service providers can be found on the Agency’s Recipient Support webpage under Additional Reference Information.

5. What are the steps I take to get BA services?

  • Go to your doctor and get a written order for BA services.
  • Have a comprehensive diagnostic evaluation completed by a qualified licensed practitioner
  • Choose a BA a provider (see question 4 above)
  • The BA provider will send a BA service request  to eQHealth for review.
  • eQHealth will review the information your provider submits and make a service determination based on the provided information and medical necessity.
  • eQHealth will notify you and the BA provider of the outcome of the review.

6. Who can I contact if I have more questions?

Please call the Medicaid helpline at 1-877-254-1055, if you have more questions.

7. Who can I contact if I am having issues with receiving BA services?

Please contact the Medicaid helpline at 1-877-254-1055 to report those issues.

8. What is a prior authorization number?

A prior authorization number is a number that is 10 digits long, has no hyphens, and begins with “5.”

BA Prior Authorization Submission Requirements

To obtain approval for Behavior Analysis services, providers must submit all new authorization requests to eQHealth Solutions, the Agency’s contracted Quality Improvement Organization for this service. For further information, please reference the following:

Comprehensive Diagnostic Evaluation Requirements

The Comprehensive Diagnostic Evaluation (CDE) is the national practice standard necessary to diagnose autism as well as other developmental or behavioral disorders and indicate the most appropriate treatment(s) to address the child’s needs. A CDE is a thorough review and assessment of the child’s development and behavior. A CDE may be performed by a multidisciplinary team or individual practitioner. In either case, the CDE must be led by a licensed practitioner working within their scope of practice. The CDE must use evidence-based practice standards, methods and instruments, and the report must include assessment findings and treatment recommendations appropriate to the recipient.  For example, CDE testing may include:
  • Parent or guardian interview
  • Teacher assessment
  • Diagnostic testing using tools such as: o   Autism Diagnostic Observation Schedule (ADOS-2)
    o   The Childhood Autism Rating Scale – 2nd edition (CARS2)
    o   Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R)
    o   Communication and Symbolic Behavior Scales (CSBS)
    o   Autism Diagnostic Interview, Revised (ADI-R)
    o   Social Communication Questionnaire
    o   Battelle Developmental Inventory– 2nd edition
  • Hearing and vision testing
  • Genetic testing
  • Neurological and/or other medical testing
To initiate behavior analysis services, the Agency requires that the provider submit a copy of the child’s Comprehensive Diagnostic Evaluation (CDE), along with all other required documentation to eQHealth Solutions, Inc.

Alternative Assessments in Pilot Regions


In the MDT regions, BA services may be initiated for a child during an excessive wait time for their scheduled CDE. When a child is on a waiting list for a scheduled CDE, eQHealth may accept the following documentation, in lieu of the CDE:
  • Scheduled CDE confirmation
  • Children 0 – 36 months of age: Early Intervention Services evaluation/Individual and Family Support Plan
  • Children older than 36 months of age:
    • Individual Education Assessment (IEP) or school district assessment for IEP
    • Neurological evaluation
    • History and physical from a licensed physician documenting behaviors and evaluation conducted to ascertain diagnosis

Authorizations without a CDE are temporary. These alternative assessments do not replace the requirements for a CDE. If parents are having difficulty finding a provider to perform the CDE, their child’s health plan is available to help. Parents can also contact the Agency at 877-254-1055 and we will work with them or their child’s plan to find a provider.

Provider Enrollment

To learn more about the provider enrollment process for behavior analysis services, please review the presentation materials on the Agency’s website. For additional assistance, please contact a customer service representative at 1-800-289-7799, Option 4.

Additional information is available on the Agency’s website: