---
title: "Ambetter from Sunshine Health (Ambetter Health Florida) ABA coverage: the intake guide."
url: "https://carelu.com/payers/ambetter-sunshine-health"
markdown_url: "https://carelu.com/payers/ambetter-sunshine-health.md"
state: FL (Florida)
payer: Ambetter from Sunshine Health (Ambetter Health Florida)
kind: Commercial insurance
description: "How Centene's Florida Marketplace plan, Ambetter (formerly Ambetter from Sunshine Health), covers ABA: no ABA benefit limit in the 2026 Evidence of Coverage, prior authorization on every ABA code, CP.BH.104 criteria, six-month authorizations, and why Florida's autism mandate does not apply."
last_reviewed: October 2026
---

# Ambetter from Sunshine Health (Ambetter Health Florida) ABA coverage: the intake guide.

_Payer Guide · Ambetter · Florida · Last updated October 2026 · 9 primary sources_

> Centene's Florida Marketplace plan (Ambetter, formerly branded Ambetter from Sunshine Health): ABA covered with no benefit limit, PA on every ABA code, outside the state autism mandate.

Ambetter is Centene's Florida Marketplace (ACA individual) product. Sunshine Health promoted it as "Ambetter from Sunshine Health"; the 2026 provider manual says it is underwritten by Centene Venture Company Florida and Sunshine State Health Plan, Inc., and the 2027 manual by Centene Venture Company Florida. It is not Sunshine Health's Medicaid plan: Florida's AHCA behavior-analysis policy does not govern it, and members pay deductibles and coinsurance. Services from non-network providers "are not covered" except emergencies.

For intake: the contract covers ABA with "No limitation" and no age limit. Every ABA code needs prior authorization under Centene's CP.BH.104. Authorizations run six months, and CP.BH.105 can recoup technician hours when protocol modification falls under 10%. Florida's autism mandate does not reach individual-market plans, so its age and dollar terms do not apply.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required. Ambetter Florida's Pre-Auth Needed tool returns "Pre-authorization is required for all providers" for 97151, 97152 and 0362T. Submit on the secure provider portal or call Utilization Management at 1-877-687-1169 [5][3]
- **Prior auth for treatment**: Required for every treatment code, 97153–97158 and 0373T ("Pre-authorization is required for all providers"), and the 2026 Evidence of Coverage says ABA services "are subject to prior authorization to determine medical necessity." Authorization periods run six months: CP.BH.105 refers to "the entire six-month authorization period," and CP.BH.104 requires an updated behavior assessment and treatment plan "at least every six months" [5][1][7][8]
- **Autism diagnosis required?**: Yes, ASD. The Evidence of Coverage covers autism services "when prescribed by a physician or behavioral health practitioner," and CP.BH.104 requires "a confirmed autism spectrum disorder (ASD) diagnosis, according to the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM)," with the severity level documented [1][7]

## At a glance

- **Product:** ACA Marketplace (Centene Venture Company Florida; 2026 also Sunshine State Health Plan) — not Sunshine Health Medicaid
- **Covers ABA?:** Yes — 2026 Evidence of Coverage, Autism Spectrum Disorder Benefits; "No limitation" on ABA
- **Prior auth:** Required for every ABA code (97151–97158, 0362T, 0373T)
- **Authorization period:** Six months; updated assessment and treatment plan at least every six months
- **PA decision clock:** Non-urgent 15 calendar days; urgent 3 calendar days
- **State mandate:** Fla. Stat. § 627.6686 (Geller Act) — excludes individual-market plans, so it does not apply
- **Claims:** Payer ID 68069; 180 days from DOS; secondary 90 days from primary EOP

## Coverage under the 2026 Evidence of Coverage

The Autism Spectrum Disorder Benefits cover autism "when prescribed by a physician or behavioral health practitioner," including "Evaluation and assessment services," "Applied behavior analysis therapy," behavior training and management, speech, occupational and physical therapy, psychiatric care, habilitation and medications. "No limitation exists within the benefits for applied behavior analysis services. These services are subject to prior authorization to determine medical necessity." A separate copayment or coinsurance applies to each provider seen on the same day. Members may choose any provider in the mental health network without a PCP referral, and non-network services are not covered except emergencies and some care at network facilities. [1][9]

Florida's Steven A. Geller Autism Coverage Act covers only group plans: its definition of "health insurance plan" "does not include any health insurance plan offered in the individual market." The Act's age terms and its $36,000 annual and $200,000 lifetime limits therefore do not apply to Ambetter. The contract itself sets no ABA limit. [1][9]

## Prior authorization, decision clocks and authorization length

The Pre-Auth Needed tool (looked up November 15, 2026) returns "Pre-authorization is required for all providers" for every ABA code: 97151–97158, 0362T and 0373T. Submit on the secure provider portal (preferred), by calling Utilization Management at 1-877-687-1169 (Relay Florida 1-800-955-8770), or on the posted fax forms. The manual's contact table lists 1-855-678-6981 in the fax column for behavioral health inpatient and outpatient prior authorization. Decision clocks: non-urgent pre-service within 15 calendar days of the request, urgent within 3 calendar days, concurrent urgent within 72 hours. [5][3][7][8]

Authorizations run six months. CP.BH.105 refers to "the entire six-month authorization period," and CP.BH.104 requires an updated behavior assessment and treatment plan at least every six months. The behavior assessment behind the first request must be no more than two months old. Renewals need session attendance (under 80% of authorized hours needs an explanation), graphed progress, caregiver-training data and a titration plan. [5][3][7][8]

## Claims and credentialing

The Ambetter payer ID is 68069. Initial claims are due 180 calendar days from the date of service (participating and non-participating), disputes and appeals 90 days from Ambetter's explanation of payment, and secondary claims 90 days from the primary payer's EOP. BCBAs are a credentialed behavioral health provider type, and recredentialing is required every 36 months. [3]

## Intake gates

The questions that decide whether a family can start with Ambetter from Sunshine Health (Ambetter Health Florida), and what they have to bring.

- **Age limit**: None stated. The Evidence of Coverage's autism benefit has no age limit and says "No limitation exists within the benefits for applied behavior analysis services," and CP.BH.104 sets none. Florida's Geller Act age and dollar terms (under 18, or in high school; $36,000 a year) do not reach this plan: § 627.6686 "does not include any health insurance plan offered in the individual market." [1][9]
- **Diagnosis recency**: Three years, with a bridge to five. To start treatment, CP.BH.104 needs a comprehensive diagnostic evaluation "conducted in the past three years," or, if the CDE is three to five years old, "A diagnostic interview/evaluation has been conducted within 12 months of the authorization request." For continuation the CDE must be within the past five years, and a re-evaluation may be required sooner. [7]
- **Who may diagnose**: "The documented diagnosis of ASD is established by a licensed physician, psychologist, or other licensed professional with specialized training in diagnosis and treatment of ASD, or a provider otherwise authorized under state law/regulation." The same class of provider makes the ABA recommendation, which "may be included within the CDE." [7]
- **Diagnostic tools required**: Two instruments minimum: the CDE must include "at least one primary clinician tool and one parent/caregiver tool." Clinician tools: STAT, ADI-R, CARS/CARS-2, ASRS, ADOS/ADOS-2, EarliPoint, RITA-T or CSBS DP-ITC. Parent tools: M-CHAT/M-CHAT-R/F, SCQ, ASSQ, CAST, SRS-2 Parent Report, SWYC POSI or CSBS DP ITC. Other evidence-based tools are reviewed case by case. [7]
- **Referral required?**: A prescription and a recommendation, but no PCP referral. The Evidence of Coverage covers autism services "when prescribed by a physician or behavioral health practitioner," and a member "do[es] not need a referral from your network primary care physician for mental or behavioral health services." CP.BH.104 requires a "Recommendation for ABA" from a licensed physician, psychologist or other qualified licensed professional, which "may be included within the CDE." No Ambetter order form is published. [1][7]
- **Prior-auth decision time**: The 2026 manual's Utilization Determination Timeframes: pre-service non-urgent "within fifteen (15) calendar days of receipt of request"; pre-service urgent "within 3 calendar days"; concurrent urgent "within 72 hours"; retrospective 30 calendar days. The 2027 manual prints the same non-urgent clock. Extensions are possible, with notice. [3][4]
- **Other insurance (who pays first)**: The Evidence of Coverage uses the birthday rule: for a child on both parents' plans, "the plan of the parent whose birthday falls earlier in the year (excluding year of birth) shall be primary," and on the same birthday "the plan which covered the parent longer will be primary." Services where "other coverage is primary to Ambetter must be first paid by the primary payor," and "Other plan will not include Medicaid." The manual allows 90 days from the primary payer's EOP to file the secondary claim. [1][3]
- **Telehealth** _(plan-dependent)_: Covered, with no ABA code list published. The Evidence of Coverage covers "medically necessary telehealth services," and telehealth outside Virtual 24/7 Care or Virtual Primary Care carries "the same cost sharing as the same health care services when delivered to a member in person." CP.BH.104 names telehealth as an ABA modality, and CP.BH.105 keeps the monthly one-on-one protocol-modification 97155 in person "unless allowed by state guidelines." Claims use POS 02 or 10 with the appropriate modifier. [1][8]
  - Ask the plan: Ambetter Florida Utilization Management 1-877-687-1169: confirm which ABA codes it will authorize by telehealth for this member.

## Delivery and billing rules

Coverage decides whether Ambetter from Sunshine Health (Ambetter Health Florida) 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**: A range, set in CP.BH.104: "Adaptive Behavior Treatment with Protocol Modification occurs for at least two hours per week or 10% of the direct service hours provided (whichever is greater), and no more than 20% of direct service hours provided (unless clinical documentation justifies)," and treatment "will be delivered or supervised by an ABA-credentialed professional." CP.BH.105 requires at least monthly one-on-one 97155 with the child "Rendered by ABA supervisor," says "Technician supervision only or team meetings do not constitute protocol modification," and lets Ambetter deny or recoup 97153/97154 units across "the entire six-month authorization period" that the 10% floor does not support. [7][8]
- **Daily limits / MUEs**: No benefit cap, but a medical-necessity ceiling. The 2026 Evidence of Coverage: "No limitation exists within the benefits for applied behavior analysis services." CP.BH.104: treatment hours "not exceed six hours per day up to a total of 30 hours per week" unless clinical documentation justifies more, and "less than 20 hours per week if attending school full-time." No per-code daily unit table is published. [1][7]
- **Session-note signature**: The rendering provider or technician signs each note. CP.BH.105 requires notes "completed prior to claim submission" with exact start and end times, pauses, location, the code and the "Signature of qualified rendering provider/technician." Clinical documentation carries the signatures and printed names of the member, legal guardian, rendering clinician/technician and supervising practitioner "as applicable." A caregiver signature is "recommended" on caregiver-training notes. Treatment plans need the signature, credentials and role of the responsible BCBA and the parent or guardian (CP.BH.104). [8][7]
- **Place of service**: Home, clinic, school and community are all contemplated. CP.BH.104: "Services may be provided in various settings (e.g., home, clinic, school, community) and modalities (e.g., in-person, telehealth)." The plan needs a "Treatment setting with rationale," and school-based ABA needs a detailed school plan with a titration plan for reducing school services. ABA is not medically necessary for "Services that are otherwise covered under the Individuals with Disabilities Education Act (IDEA)." Telemedicine claims are billed with POS 02 or 10 per the manual. [7][3]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not stated as a billing rule. CP.BH.105 says "97155 may be used to demonstrate new or modified protocol to a technician with the member/enrollee present," but no Ambetter Florida document says whether the technician's 97153 for the same minutes also pays. [8]
  - Ask the plan: Ambetter Florida Utilization Management / Provider Services 1-877-687-1169: ask whether 97153 and 97155 both pay for the same clock time.
- **Bill as provider** _(ask the plan)_: Not settled by a published ABA rule. The manual lists BCBA among credentialed behavioral health provider types, with no technician or BCaBA type, and does not say whose NPI carries RBT time. The Evidence of Coverage adds: "If multiple services are provided on the same day by different providers, a separate copayment and/or coinsurance will apply to each provider." [3][1]
  - Ask the plan: Ambetter Florida Provider Services 1-877-687-1169 or your Provider Partnership Representative: ask whether technician 97153 goes out under the supervising BCBA's NPI.

## What intake should collect for Ambetter from Sunshine Health (Ambetter Health Florida)

- **Ambetter card:** Marketplace Ambetter, not Sunshine Health Medicaid; note the plan (Ambetter, Ambetter Value) because networks differ and non-network care is not covered.
- **Comprehensive diagnostic evaluation:** Within 3 years (or 3–5 years plus a diagnostic interview within 12 months), with one clinician and one parent tool.
- **Recommendation for ABA:** From the diagnosing physician, psychologist or qualified licensed professional; it may sit inside the CDE.
- **Other coverage:** Birthday rule between parents' plans; Medicaid is never "other plan" here.

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

## Common questions

### Does Ambetter from Sunshine Health cover ABA therapy?

Yes. The 2026 Evidence of Coverage covers applied behavior analysis for autism when prescribed by a physician or behavioral health practitioner, with "No limitation" on the ABA benefit. Prior authorization, network rules and cost sharing apply.

### Does Florida's autism mandate apply to Ambetter?

No. The Geller Act (§ 627.6686) covers group plans and "does not include any health insurance plan offered in the individual market." Ambetter's own contract sets no ABA limit and no age limit.

### Which ABA codes need prior authorization with Ambetter in Florida?

All of them: 97151–97158, 0362T and 0373T, per the Pre-Auth Needed tool. Call Utilization Management at 1-877-687-1169 or use the provider portal.

### How long does an Ambetter Florida ABA authorization last, and how long is the decision?

Six months per authorization, with an updated assessment and treatment plan each time. Non-urgent requests are decided within 15 calendar days, urgent within 3.

### What is the Ambetter Florida timely filing limit?

180 calendar days from the date of service, and 90 days from the primary payer's EOP for secondary claims. The payer ID is 68069.

## Primary sources

1. [Ambetter Health (Centene Venture Company Florida) — 2026 Evidence of Coverage (49004FL001-2026)](https://api.centene.com/EOC/2026/49004FL001.pdf)
2. [Ambetter Health (Florida) — 2026 plan documents (Evidence of Coverage index)](https://www.ambetterhealth.com/en/fl/2026-brochures/)
3. [Ambetter Health (Florida) — 2026 Provider and Billing Manual](https://www.ambetterhealth.com/content/dam/centene/Sunshine/Ambetter/PDFs/2026-fl-provider-manual.pdf)
4. [Ambetter Health (Florida) — 2027 Provider and Billing Manual](https://www.ambetterhealth.com/content/dam/centene/Sunshine/Ambetter/PDFs/2027-fl-provider-manual.pdf)
5. [Ambetter Health (Florida) — Pre-Auth Needed tool (code lookups 2026-11-15)](https://www.ambetterhealth.com/en/fl/provider-resources/manuals-and-forms/pre-auth/)
6. [Ambetter Health (Florida) — Manuals and Forms](https://www.ambetterhealth.com/en/fl/provider-resources/manuals-and-forms/)
7. [Clinical Policy CP.BH.104 — Applied Behavior Analysis (Ambetter Florida copy; last revision 02/26)](https://www.ambetterhealth.com/content/dam/centene/Sunshine/Ambetter/policies/clinical-policies/CP.BH.104.pdf)
8. [Clinical Policy CP.BH.105 — Applied Behavioral Analysis Documentation Requirements (Ambetter Florida copy; last revision 02/26)](https://www.ambetterhealth.com/content/dam/centene/Sunshine/Ambetter/policies/clinical-policies/CP.BH.105.pdf)
9. [Fla. Stat. § 627.6686 (2026) — Steven A. Geller Autism Coverage Act](https://www.flsenate.gov/Laws/Statutes/2026/627.6686)

Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 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.