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Behavior Analysis (BA) — Provider Quick Reference Guide

Important Contact Information

  • Provider Services      
    • All products   
    • 1-844-477-8313        
    • Monday-Friday from 8 a.m. to 8 p.m. Eastern
  • Pharmacy Services   
    • All products   
    • 1-800-460-8988, option 2    
    • 24 hours a day, 7 days a week
  • Member Services
    • Comprehensive MMA, SMI, HIV/AIDS
    • Child Welfare Specialty Plan  (CWSP)
    • Children Medical Services (CMS) Title 19 and Title 21 
    • Ambetter

Verifying Member Eligibility

These suggestions are not a guarantee of coverage.

  • Verify member eligibility by using the Sunshine Health Secure Provider Portal to confirm eligibility quickly and efficiently.
  • Using the portal, any registered provider is able to quickly check member eligibility by entering the member’s name and date of birth, or Medicaid ID number and date of birth, along with the date of service.
  • It is essential to select the correct “Plan Type” when performing an eligibility search to ensure accurate results.
  • Member Coordination of Benefits (COB) information can also be found in the Secure Provider Portal.
  • Alternatively, you can call Provider Services at 1-844-477-8313. Please provide the member's name and date of birth or their Medicaid ID number and date of birth.

Member ID Cards

Sunshine (Comprehensive MMA, CWSP, SMI, HIV/AIDS)

Medicaid Member ID card

Children Medical Services (CMS) Title XXI (21)

CMS Health Plan Title 21 Member ID Card

Children Medical Services (CMS) Title XIX (19)

Ambetter Premier (formerly known as Core)

Ambetter Health Premier Member ID Card (Core)

Ambetter Value

Ambetter Health Value Member ID Card

Definitions:

  • MMA (Managed Medical Assistance): This Medicaid program provides comprehensive medical and behavioral health services, including ABA services, to Medicaid recipients who opted out of a specialized plan.
  • SMI (Serious Mental Illness Specialty Plan): This Medicaid program offers medical and behavioral health services, including ABA services, to members aged 6 and older who have one or more of the following conditions: psychotic disorders, delusional disorder, bipolar disorder, schizoaffective disorder, obsessive-compulsive disorder and major depression.
  • CWSP (Child Welfare Specialty Plan): This Medicaid program provides medical and behavioral health services, including ABA services, to children in the child welfare system, including those in foster care, receiving adoption services, or at risk of being removed from their homes.
  • HIV/AIDS Specialty Plan: This Medicaid program offers specialized healthcare services to individuals living with HIV/AIDS.
  • Children Medical Services (CMS): This program is designed for individuals who are eligible for Medicaid or KidCare and have special healthcare needs.
    • CMS Title XIX (19): This Medicaid program provides medical and behavioral health services, including ABA services, to members ages 0-18 years with special healthcare needs who qualify for Medicaid coverage. There is no copayment or premium cost to the member.
    • CMS Title XXI (21): Children’s Health Insurance Program (CHIP): This program provides medical and behavioral health services, including ABA services, to children ages 1-18 years with special healthcare needs who qualify for KidCare. These individuals are not Medicaid recipients. There may be a copayment or premium cost for the member, which is determined by family income.
  • Ambetter Health/Marketplace
    • Premier Plan: This product has our broadest network of healthcare providers and hospitals.
    • Value Plan: This product has particular healthcare providers and hospitals in the network. This plan requires a referral to providers outside the members’ assigned Primary Care Provider.

Continuity of Care (COC)

Sunshine Health coordinates BA services for all members who are new to our plan to ensure there is no interruption in care. This process ensures continuous care for members with previous authorizations or who are undergoing an active course of treatment. This includes care previously authorized to a non-participating provider. Effective February 1, 2025, the continuity of care (COC) period for new BA Comprehensive MMA, SMI, CWSP, HIV/AIDS and CMS Title 19 members is 120 days from the date of eligibility for this transitional period.

After the effective date of the new enrollment:

  • Providers should continue providing all medically necessary services that were previously authorized, regardless of whether the provider is participating in the plan’s network. Sunshine Health will pay for previously authorized services for up to 120 days for Comprehensive MMA, SMI, CWSP, HIV/AIDS and CMS Title 19 members.
  • For Comprehensive MMA, SMI, CWSP, HIV/AIDS and CMS Title 19 members, Sunshine Health will pay for previously authorized services for up to 120 days after the effective date of enrollment and pay providers at the rate previously received for up to 60 days.
  • For enrollees that change plans during the initial Continuity of Care Period (COC), the Managed Care Plan will coordinate with the previous plan to ensure existing prior authorizations will be honored.
  • For existing authorizations with approaching end dates, submit requests to Sunshine Health starting January 16, 2025, for start dates February 1, 2025, and beyond.
  • During the transition of care, we will backdate a request up to 30 calendar days.
  • Out-of-network providers will be authorized during the COC period or until the authorization expires, whichever occurs first. Members must select an in-network provider and BA services will require prior auth after the COC period ends.

Note: The 120-day COC period applies exclusively to newly enrolled members during the February 1, 2025 transitional period, as a result of the inclusion of Behavior Analysis Services in the Statewide Medicaid Managed Care (SMMC) Program. You may reference Sunshine Health’s MMA Provider Manual for our standard COC time frames.

BA Authorizations

Prior authorization is required for all BA services. When necessary, please refer to our Pre-Auth Check Tool.

Prior-authorization requests are processed by Sunshine Health’s Utilization Management (UM) Department.

  • Standard requests: Determination within 5 calendar days of receipt of request.
  • Urgent requests: Please call 1-844-477-8313. Urgent requests are made when the member or their physician believes that waiting for a decision under the standard timeframe could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy.
  • BA prior authorization requests can be submitted for up to 6 months of services.

Submit authorization requests via one of the following:

  • Online: via the Sunshine Health Secure Provider Portal
  • Utilization Management Phone number: 1-844-477-8313
  • BA Fax: 1-844-208-9113
  • Pharmacy Services Fax: 1-833-546-1507
  • Standard hours of operation: Monday- Friday from 8 a.m. to 8 p.m. Eastern
  • Weekend and After-Hours on Call-Numbers (For All Products): 1-844-477-8313

Required Documentation

All documentation must reflect the individual assessments, needs and interventions of the recipient.

Initial Behavior Assessment and Behavior plan requests:

  • A referral for BA services is required as follows:
    • The recipient must be referred by an independent physician or practitioner qualified to assess and diagnose disorders related to functional impairment, including:
      • Primary care physician with family practice, internal medicine or pediatrics specialty;
      • Board certified or board eligible physician with specialty in developmental behavioral pediatrics, neurodevelopmental pediatrics, pediatric neurology, adult or child psychiatry
      • Child psychologist

Comprehensive Diagnostic Evaluation (CDE)

The initial assessment must include the administration, scoring and reporting of two core standardized behavior instruments as follows:

  • The Vineland-3 and BASC-3 PRQ core assessments are required to be included for initial assessment and annually for reassessments.

Behavior Assessment and Behavior Treatment plan

  • Providers should request re-assessment units with their treatment request.
  • Florida Medicaid Behavior Analysis service policy identifies a 40-hour per week limit for behavior analysis services.
  • Behavior assessment and behavior plan with specific criteria are listed in the Florida Medicaid Behavioral Analysis Coverage Policy (PDF).
  • The behavior assessment and behavior plan must be signed by the Lead Analyst and the recipient’s parent or guardian.

Assessment and Behavior Plan for Reauthorization and Continuation of Services

  • In addition to the documentation requirements indicated in Florida Medicaid Behavioral Analysis Coverage Policy (PDF), assessments and behavior plans for reauthorization and continuation of services must include:
  • Data reflecting progress of all behaviors targeted for improvement. Each behavior under treatment must have its own data table and corresponding graph. A narrative discussion of progress and a statement of justification for continuation of care at the intensity level requested. If significant clinical progress is not made over the course of an authorization period, the provider must explain why clinically significant progress was not made and treatment changes to promote progress.

Note: Please use the Treatment/Service Request Forms for fax submission.

BA services must be rendered by one of the following:

  1. Lead Analysts who are one of the following:
    • Board certified behavior analyst (BCBA) credentialed by the Behavior Analyst Certification Board.
    • Florida certified behavior analyst (FL-CBA) credentialed by the Behavior Analyst Certification Board.
    • Practitioner fully licensed in accordance with Chapters 490 or 491, F.S., performing within their scope of practice.
  2. Board certified assistant behavior analysts (BCaBA) credentialed by the Behavior Analyst Certification Board working under the supervision of a BCBA.
  3. Registered behavior technicians (RBT) credentialed by the Behavior Analyst Certification Board working under the supervision of a BCBA or BCaBA.

Claims

Behavioral Analysis (BA) Covered Services

Behavior analysis (BA) services are covered for CMS Title 21 and Title 19 members. They are highly structured interventions, strategies, and approaches provided to decrease maladaptive behaviors and increase or reinforce appropriate behaviors for members. For more information about covered services, refer to AHCA’s Behavior Analysis Services Provider Information resource.

Description of the Specialty: Behavior analysis (BA) services are highly structured interventions, strategies, and approaches provided to decrease maladaptive behaviors and increase or reinforce appropriate behaviors.

Methods for Claims Submission

For both paper and electronic data interchange (EDI) claim submissions starting February 1, 2025, the appropriate Center for Medicare and Medicaid Services (CMS) billing forms are required:

  • CMS 1450 (UB04) for facilities.
  • CMS 1500 for professionals.

There are several ways to submit claims to us:

Claims Submissions

Health Plan

Claim Type

Payer ID #

Paper Claim Mailing Address

Sunshine Health, CMS, SMI, CWSP, HIV/AIDS

Professional and Institutional

Sunshine Health: 68069

 

Attn: Claims Department

P.O. Box 3070

Farmington, MO 63640- 3823

Ambetter Health

Professional and Institutional

68069

Attn: Claims Department

P.O. Box 5010

Farmington, MO 63640-5010

Note: Please reference the vendor provider manuals for their individual payer IDs.

Billing: In general, Sunshine Health follows Centers for Medicare & Medicaid Services (CMS) billing requirements. Please refer to your contract to determine contracted products, negotiated rates, and Fee Schedules. For additional questions, contact Sunshine Health Provider Services at 1-844-477-8313.

Clean claims will be adjudicated (finalized as paid or denied) at the following levels:

  • 50% of all clean claims submitted within seven days.
  • 70% of all clean claims submitted within 10 days.
  • 90% of all clean claims submitted within 20 days.

Adjusted claims, requests for reconsideration and disputed claims will be finalized to a paid or denied status 30 calendar days of receipt.

For additional questions, contact Sunshine Health Provider Services at 1-844-477-8313 or Ambetter Health Provider Services at 1-877-687-1169.

Important Links

Timely Claim Submission

Providers must submit claims in a timely manner as indicated in the following table.

Initial Claim*

Reconsiderations or

Claim Dispute**

Coordination of Benefits***

Participating

Non-Participating

Participating

Non-Participating

Participating

Non-Participating

180 days

365 days

90 days

180 days

90 days

90 days

*In an initial claim, days are calculated from the date of service to the date received by Sunshine Health.

** In a reconsideration or claim dispute, days are calculated from the date of the explanation of payment/correspondence issued by Sunshine Health to the date the reconsideration is received by Sunshine Health.

*** For coordination of benefits, days are calculated from the date of explanation of payment from the primary payer to the date received by Sunshine Health.

Overpayment Refund Address  

When a facility, group or practice identifies an overpayment, a refund should be submitted to the address indicated below to include all applicable claims for which the refund is being submitted.  

Sunshine Health 
Attn: Centene Mgmt. Co - Sunshine State Health Plan 
P.O. Box 947986 
Atlanta, GA 30394-7986

Remittances and PaySpan

If you are currently receiving paper checks and would like to switch to Electronic Funds Transfer (EFT), please register with PaySpan.

Register by visiting PaySpan’s website, calling 1-877-331-7154 or emailing providersupport@payspanhealth.com. If your address is incorrect in PaySpan, please update it.

Update Provider Demographics

Providers can use the Provider Demographic Updates form to quickly update their practice information or call 1-844-877-8313.

Credentialing and Provider Changes

To add a new practitioner or facility to your existing Sunshine Health contract please visit the Practitioner Enrollment Request page. This form is restricted for adding a practitioner or facility to an existing, contracted group. If the tax ID is not currently contracted with Sunshine Health, please submit a request to Join Our Network. If a request is submitted for a non-contracted group, the request will be returned to you unprocessed.

Important: Practitioners should not begin servicing Sunshine Health members until they have received a Provider Enrollment Confirmation letter from Sunshine Health’s Provider Enrollment department. Our enrollment process can take up to sixty (60) days to complete. We will not backdate effective dates due to services provided ahead of the practitioner’s enrollment. For more information, visit:

Contracting

Sunshine Health takes proactive actions that are aimed at creating a comprehensive and high-quality network that meets the needs of its members while ensuring access to necessary services. If you are a non-contracted provider, please submit your request to join our network.

Note: Submitting this inquiry is an important first step in the process, but it does not guarantee entry into our network. This form is not the same as a credentialing application or a signed agreement. The information you provide will be used solely by Sunshine Health to evaluate the potential for offering a new contract, amending an existing one, or adding an additional product to an existing contract. We appreciate your interest and will carefully review your submission.

All contract rate discussions for participating providers are unique and confidential, if you have questions please email sunshinecontracting@sunshinehealth.com and a representative will reach out to speak with you.

Case Management

Our Case Management team can be reached Monday to Friday from 8 a.m. to 8 p.m. via the phone numbers below. For after-hours or weekend assistance, select option 7.

Member Referrals to Case Management 

Referrals can be submitted through the Secure Provider Portal under the “Referrals” tab of the Member’s Record. After successful submission, a message will appear confirming this. 

24-Hour Nurse Advice Line and Crisis Line

The Nurse Advice Line can assist providers with checking member eligibility. It can also connect members to telemedicine for urgent care visits. The same number also has a Behavioral Health Crisis Line. Hours of operation are 24 hours a day, 7 days a week.

  • CMS: 1-866-799-5321 and follow prompts for Nurse Advice Line, Option 1, then select Option 7.
  • MMA and SMI: 1-866-796-0530 and follow prompts for Nurse Advice Line, select Option 1, then Option 3, then Option 7.
  • CWSP: 1-855-463-4100 and follow prompts for Nurse Advice Line, select Option 1, then Option 2, then Option 7.
  • Ambetter Health: 1-877-687-1169 (Relay Florida 1-800-955-8770). Available 24-7, 365 days a year.

988 - Suicide & Crisis Hotline 

If you are struggling with alcohol or drug use, experiencing ongoing anxiety or depression, or experiencing a crisis, dial or text 988, or chat with a trained counselor at 988lifeline.org/chat. This service is confidential, free of charge, and available 24/7, 365 days a year.

Provider Engagement

Sunshine Health has a team of Provider Engagement Account Managers throughout Florida, who are committed to supporting providers and addressing your needs. Learn more about how Provider Engagement can help you.

Our Account Managers are available to assist with a variety of services designed to support the success of your practice. These professionals spend three or more days each week directly engaging with providers in the field.

For inquiries related to operational issues, we kindly ask that you direct these to our dedicated providers service team at 1-844-877-8313 who are equipped to handle those requests promptly and efficiently.

To identify your designated Account Manager, visit our Find Your Account Manager tool.

Additional Resources

  • Access and Availability Timeframe Standards: Sunshine Health establishes and assesses compliance with appointment wait times for various types of visits. Please view Standards for Appointment Scheduling.
  • Find A Provider (FAP) Tool: If you need assistance locating a specialist or facility for a member, please visit our Find a Provider tool. Here you will be able to search by provider name, NPI and specialty type.
  • Community Resources: Our Sunshine Health Community Resource Database connects members and caregivers in need with local programs and supports.
  • For Providers: Stay up to date on provider communication by visiting For Providers and Provider News. On this page, providers can also subscribe to our monthly newsletter.
  • Vendors: Contact information for Sunshine Health’s subcontractors and vendors.