---
title: Humana Healthy Horizons in Florida ABA / BA coverage (MMA plan).
url: "https://carelu.com/payers/humana-healthy-horizons-florida"
markdown_url: "https://carelu.com/payers/humana-healthy-horizons-florida.md"
state: FL (Florida)
payer: Humana Healthy Horizons in Florida
kind: Medicaid managed care plan (MCO)
parent_program: Florida Medicaid (AHCA)
description: "How Humana Healthy Horizons administers Florida Medicaid Behavior Analysis — Availity, 24/7 IVR and fax channels, the Behavior Analysis Authorization form, documentation requirements, named regional BA reps, and non-par payment at 80% of the state fee schedule."
last_reviewed: October 2026
vob_data_updated: 2026-10-15
---

# Humana Healthy Horizons in Florida ABA / BA coverage (MMA plan).

_Payer Guide · Humana Healthy Horizons (FL) · Last updated October 2026 · 9 primary sources_

> Widest channels of the nine (Availity, 24/7 IVR, fax), named BA reps, non-par paid at 80% of the state fee schedule.

Humana Healthy Horizons administers Florida's Behavior Analysis benefit in-house on the AHCA criteria, and differentiates on access: the broadest channel set of the nine plans (Availity Essentials preferred, a 24/7 IVR line, and fax), a dedicated BA provider-relations mailbox with named regional reps, and an unusually explicit rate anchor — absent a letter of agreement, non-participating providers are paid 80% of the Florida Medicaid fee schedule, the figure printed on Humana's own authorization form. For members who change plans, Humana's current flyer commits to “continuing care plan as is for up to 90 days.”

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 Availity Essentials (preferred), IVR 800-523-0023 (24/7), or fax 813-321-7220, on Humana's Behavior Analysis Authorization form; the initial assessment request attaches the BA referral and the Comprehensive Diagnostic Evaluation [2][3][4]
- **Prior auth for treatment**: Required — same channels; PA list at Humana.com/PAL [2][3][4]
- **Autism diagnosis required?**: No — state BA policy applies: physician referral + order + CDE, no autism-diagnosis requirement [5]

## At a glance

- **Plan type:** SMMC MMA plan (Humana), in-house UM
- **Clinical rules:** AHCA BA Coverage Policy; Behavior Analysis Authorization form (1023905FL0616)
- **Prior auth:** Availity (preferred), IVR 800-523-0023 (24/7), or fax 813-321-7220
- **Documentation:** Referral + CDE (assessment); behavior plan, Vineland-3 + BASC-3 PRQ (initial + every 12 months), hours rationale, IEP/504 if school-based (treatment)
- **Claims:** Availity payer ID 61101; clean claims in 20 days; non-par paid 80% of the state fee schedule absent a letter of agreement
- **BA support:** FLBA@humana.com + named regional reps; provider line 800-477-6931

## How Humana runs BA authorization

PA is required for all BA services and can be initiated three ways: Availity Essentials (Humana's preferred channel), the 24/7 IVR at 800-523-0023, or fax to 813-321-7220, using Humana's Behavior Analysis Authorization form (1023905FL0616), which Humana says “should be completed and included with your authorization request.” The documentation list tracks the state policy closely: a BA referral and the Comprehensive Diagnostic Evaluation for the initial assessment; then the signed behavior plan, the Vineland-3 and the BASC-3 PRQ for ages 2–18 (at initial assessment and every 12 months), a rationale for the requested hours, and the IEP or 504 plan when services are provided in school. For authorization status, call 866-856-8974. The plan's full PA list lives at Humana.com/PAL. Uniquely among the nine, Humana publishes a dedicated BA provider-relations structure: the FLBA@humana.com mailbox plus named regional representatives covering Regions A–E and F–I — for an intake team, a saved contact sheet turns authorization questions into emails with a named owner. Non-par contracting starts at RequestToJoin@humana.com. [2][3][4]

## Rates and claims: the fee-schedule anchor

Participating providers bill at contracted rates (claims via Availity, payer ID 61101; paper to Humana's Lexington, KY claims office), with clean claims processed within 20 days. The notable rate fact: absent a controlling legal requirement or letter of agreement, the current flyer limits non-participating providers to the lesser of “the amount specified by Humana Healthy Horizons in the authorization request form” or “100% of the applicable Medicaid fee schedule,” and the authorization form specifies the amount: non-par providers “will be reimbursed at 80% of the Medicaid Fee Schedule.” That makes the state's low BA rates (97153 at $12.26/unit) the reference point for any Humana negotiation. Continuity of care: for members who change plans, Humana coordinates with the previous plan to honor prior authorizations and commits to “continuing care plan as is for up to 90 days.” The carve-in continuity window of February 2025 has long closed. [2][3]

## How fast must Humana Healthy Horizons pay an ABA claim?

Florida writes the claim clock for Medicaid health plans, Humana Healthy Horizons included into statute: “Managed care plans shall comply with ss. 641.315, 641.3155, and 641.513” (§ 409.967(2)(j)). Under § 641.3155 a provider must send the claim to the plan “within 6 months after” the date of service (and to a secondary payer within 90 days of the primary’s final determination). For an electronic claim the plan must acknowledge receipt within 24 hours of the next business day and, within 20 days, pay it or notify the provider that it is denied or contested, with an itemized list of what is missing (the provider then has 35 days to supply it). Every claim must be paid or denied within 90 days of receipt, and failure to do so within 120 days “creates an uncontestable obligation to pay the claim.” Paper claims run 40, 120 and 140 days. Late payments bear 12% simple interest. [1][7][8]

Humana’s own 2026 manual: “Providers must submit claims within 6 months of the date of service,” and when Humana is secondary to a payer other than Medicare, “within 90 calendar days of the final determination of the primary payer.” Medicare crossovers cannot be denied for timing unless more than 3 years have passed. Humana publishes no weekly submission cutoff or check-run day. [1][7][8]

## Intake gates

The questions that decide whether a family can start with Humana Healthy Horizons in Florida, and what they have to bring.

- **Age limit**: Follows the Florida Medicaid rule: BA is for recipients under the age of 21, with EPSDT available above the coverage-policy and fee-schedule limits. Humana’s BA informational flyer and ABA toolkit publish no plan-specific age limit, and the state policy forbids a plan from applying more stringent service coverage limits. [5][2]
- **Diagnosis recency**: No autism diagnosis is required. Humana’s own instrument clock tracks the state cycle: its Behavior Analysis Authorization form requires the BASC-3 PRQ for ages 2 through 18 and the Vineland-3 Comprehensive Parent Interview Form for all recipients, each at the initial assessment and every 12 months, on top of the state’s reassessment and updated behavior plan at least every six months. The Comprehensive Diagnostic Evaluation itself carries no published expiry. [3][5]
- **Who may diagnose**: The state rule, restated in Humana’s documentation list: the initial assessment request attaches a referral for BA services and a “comprehensive diagnostic evaluation from a qualified practitioner,” and the behavior plan must carry “the diagnosis and treatment order from the licensed provider,” with the referral coming from an independent physician or qualifying practitioner and the CDE led by a licensed practitioner working within their medical, developmental or psychological scope of practice. Humana publishes no narrower list of its own. [3][5]
- **Diagnostic tools required**: Humana’s Behavior Analysis Authorization form names both state instruments as required treatment-request attachments: the Vineland-3 Comprehensive Parent Interview Form for all recipients, plus the Maladaptive Behavior domain for ages 3 and older, and the BASC-3 PRQ for ages 2 through 18 — each “initial assessment and every 12 months.” The state policy requires complete scoring reports. [3][5]
- **Referral required?**: Required, and Humana publishes the fullest documentation list of the nine plans on its Behavior Analysis Authorization form (1023905FL0616): for the initial assessment, a referral for BA services and the Comprehensive Diagnostic Evaluation; for treatment, the behavior plan signed by the lead analyst and parent, medical/developmental and family history, the Vineland-3 and BASC-3 PRQ, “clinical documentation of recommendation for services, outlining rationale for quantity in hours per week/day,” and the IEP or 504 plan when services are provided in school — submitted through Availity Essentials (preferred), the 24/7 IVR at 800-523-0023, or fax 813-321-7220 (authorization status line 866-856-8974). Humana’s current flyer adds that “the Behavior Analysis Authorization form should be completed and included with your authorization request” and that “a valid Medicaid ID is required for all providers, whether located in Florida or out of state, as a condition of payment.” [2][3][5]
- **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. Humana’s BA informational flyer and ABA toolkit publish no telehealth code list, modifier set or place-of-service rule for Florida BA. [5][2]
  - Ask the plan: Humana’s Florida BA mailbox (FLBA@humana.com) or the provider line 800-477-6931 before scheduling a remote session other than 97156 caregiver training.
- **Prior-auth decision time**: Humana’s 2026 Florida provider handbook publishes no decision timeframe for PA requests. Its PA page says only that requests “should be made as soon as possible.” The contract clock therefore 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. Humana’s BA request must include a current assessment “from within the past 60 days,” so time the reassessment to the submission. No reauthorization lead time is published. [1][10][11]
- **Other insurance (who pays first)**: Humana’s handbook says only: “Humana Healthy Horizons assumes full responsibility for collections in the event of third-party liability.” It publishes no step-by-step rule on billing the other payer first. The state rule that binds every MMA plan still applies. 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. [1][12][11]
  - Ask the plan: Humana Provider Services (IVR 800-523-0023): whether Humana wants the commercial EOB before its claim, and whether its BA authorization is still required when a commercial plan pays first.

## Delivery and billing rules

Coverage decides whether Humana Healthy Horizons in 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**: The state floor: supervision of BCaBAs and RBTs per the Council of Autism Service Providers practice standards, specified in the supervision plan inside the approved behavior plan, which names the authorized supervisors. Humana adds no ratio or caseload cap — but its authorization form asks for a rationale for the requested hours per week/day with every treatment request, and the provider signs that “the licensed psychologist or BCBA is responsible for all aspects of clinical direction, supervision and case management.” [5][3]
- **Concurrent billing (97153 + 97155)**: The state rule governs and Humana 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. [5]
  - Ask the plan: Humana’s Florida BA mailbox (FLBA@humana.com) or the named regional BA representative for whether an authorization may carry 97153 and 97155 on the same clock time.
- **Daily limits / MUEs**: The state weekly ceiling of up to 40 hours per week of BA intervention as prior-authorized in the behavior plan, with EPSDT available above it and group treatment capped at six participants. Humana bills “reimbursement for all services in 15-minute increments” and requires add-on codes to be billed with the corresponding base code. No per-day unit table is published. [5][2]
  - Ask the plan: Humana provider services (800-477-6931) for per-day claim edits; the AHCA fee schedule under Rule 59G-4.002 for per-assessment unit caps.
- **Session-note signature**: The state rule: session notes signed and dated by the rendering practitioner, carrying date, time, location, duration, behaviors observed, skills targeted, the recipient’s response, protocol modification or therapist direction, an explanation if the parent or guardian was absent, and the participants; the behavior assessment and behavior plan signed by the Lead Analyst and the parent or guardian. Humana publishes no additional signature rule for BA. [5][2]
- **Place of service**: Humana makes the state school rule an explicit line item on its authorization form — the IEP including BA services, or the 504 plan, “if services are provided in school,” and the form’s place-of-service boxes are Home, Office/Center, School or Other — and the state rule supplies the rest: in the absence of an IEP, documentation justifying the services plus an estimated IEP timeframe; 1:1 shadow, personal care, companion and chaperone services non-covered regardless of setting; travel time non-covered. [3][5]
- **Bill as provider**: Humana publishes the box-by-box rule: “use the CMS-1500 form to submit claims for behavioral analysis services”; if the rendering provider is in a group and the group is being paid, “the group will be captured in the billing provider section (Box 33), and then the rendering provider will be captured in the rendering provider section (Box 24)”; if the rendering provider is the one being reimbursed, they go in Box 33; and “enter the individual rendering (treating) provider’s number in Item 24 J… only when it is different from the pay-to provider number.” Claims go out under payer ID 61101 through Availity (paper to the Lexington, KY claims office), clean claims process within 20 days, and, absent a letter of agreement, non-participating providers are paid the lesser of “the amount specified by Humana Healthy Horizons in the authorization request form” or “100% of the applicable Medicaid fee schedule” — and the authorization form itself specifies that non-par providers “will be reimbursed at 80% of the Medicaid Fee Schedule.” [2][3][5]

## What intake should collect for Humana Healthy Horizons in Florida

- **Referral + CDE:** The BA referral and the CDE attach to Humana's initial assessment request — collect them at intake.
- **Vineland-3 + BASC-3 PRQ scoring reports:** Required on Humana's form at initial assessment and every 12 months (BASC-3 PRQ for ages 2–18).
- **Hours rationale:** Humana asks for the rationale behind requested hours — align clinical planning with the ask.
- **School status + IEP/504:** Required with school-based requests.
- **Regional BA rep:** Identify the named Humana rep for your region and save the FLBA@humana.com contact.

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

## Verification of benefits (VOB) data

How Humana Healthy Horizons in Florida ABA benefits route and read on an eligibility check. Data last updated 2026-10-15.

### EDI routing

- **Payer ID (Availity):** 61101
- **Behavioral health administrator:** none
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### 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. Humana's own materials explicitly defer coding mechanics to AHCA in writing: "Procedure codes and the latest published fee schedules can be found on the AHCA website... Rule 59G-4.002." Non-par providers are reimbursed at 80% of the Florida Medicaid fee schedule, absent a controlling legal requirement or Letter of Agreement (Behavior Analysis Authorization form 1023905FL0616, p.3) — a concrete figure, not the vague "a percentage of..." previously on file. These are the statewide AHCA BA Coverage Policy mechanics, binding on Humana Healthy Horizons in Florida per the policy's plan-compliance clause (§1.2); Humana Healthy Horizons in Florida's own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Humana Healthy Horizons in Florida provider relations before quoting a family.
- **97152, 97156, 97158:** These are the statewide AHCA BA Coverage Policy mechanics, binding on Humana Healthy Horizons in Florida per the policy's plan-compliance clause (§1.2); Humana Healthy Horizons in Florida's own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Humana Healthy Horizons in Florida 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). These are the statewide AHCA BA Coverage Policy mechanics, binding on Humana Healthy Horizons in Florida per the policy's plan-compliance clause (§1.2); Humana Healthy Horizons in Florida's own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Humana Healthy Horizons in Florida provider relations before quoting a family.
- **97154:** The modifier documents group size, not staff credential — rate scales DOWN as the group grows. These are the statewide AHCA BA Coverage Policy mechanics, binding on Humana Healthy Horizons in Florida per the policy's plan-compliance clause (§1.2); Humana Healthy Horizons in Florida's own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Humana Healthy Horizons in Florida provider relations before quoting a family.
- **97155:** Rendered by Lead Analyst or BCaBA only — RBTs do not bill 97155 in Florida. These are the statewide AHCA BA Coverage Policy mechanics, binding on Humana Healthy Horizons in Florida per the policy's plan-compliance clause (§1.2); Humana Healthy Horizons in Florida's own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Humana Healthy Horizons in Florida 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. Independently cross-confirmed absent from the Humana FL PAL too — not just the AHCA fee schedule. These are the statewide AHCA BA Coverage Policy mechanics, binding on Humana Healthy Horizons in Florida per the policy's plan-compliance clause (§1.2); Humana Healthy Horizons in Florida's own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Humana Healthy Horizons in Florida 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. These are the statewide AHCA BA Coverage Policy mechanics, binding on Humana Healthy Horizons in Florida per the policy's plan-compliance clause (§1.2); Humana Healthy Horizons in Florida's own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Humana Healthy Horizons in Florida 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. These are the statewide AHCA BA Coverage Policy mechanics, binding on Humana Healthy Horizons in Florida per the policy's plan-compliance clause (§1.2); Humana Healthy Horizons in Florida's own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Humana Healthy Horizons in Florida provider relations before quoting a family.

### Contacts

- **Provider services phone:** 800-477-6931
- **Phone menu path:** Prior-authorization IVR: 800-523-0023, available 24/7 (live representatives Monday–Friday, 8 a.m.–8 p.m. Eastern).
- **Hours:** Participating and nonparticipating providers: Monday–Friday, 8 a.m.–8 p.m. Eastern.
- **Portal:** [Availity Essentials](https://www.availity.com/)
- **Fax:** 813-321-7220

Questions to ask on a verification call:

- What payer ID should we use for pVerify and Change Healthcare eligibility checks, and do you support 270/271 real-time eligibility on Availity ID 61101, or is it batch only?
- Which service-type code do you return ABA benefit details under?
- Does the deductible apply to ABA, 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://assets.humana.com/is/content/humana/ABA_Informational_Flyer_AHCApdf (accessed 2026-09-27)
- 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://assets.humana.com/is/content/humana/ABA_PA_Formpdf (accessed 2026-09-27)
- https://assets.humana.com/is/content/humana/FL%20MCD%20PAL%20Cpdf (accessed 2026-07-23)

## Common questions

### What is Humana Healthy Horizons’ timely filing limit for ABA claims in Florida?

Six months from the date of service, per Humana’s 2026 Florida Medicaid manual; when Humana pays second to a non-Medicare payer, 90 calendar days from the primary payer’s final determination.

### Does Humana Healthy Horizons cover ABA in Florida?

Yes — it administers the state Behavior Analysis benefit on AHCA criteria: no autism diagnosis required, physician referral + order + CDE, PA on all BA services via Availity, 24/7 IVR, or fax.

### What documents does a Humana Florida BA authorization need?

For the initial assessment, a BA referral and the CDE. For treatment, the signed behavior plan, history and care-coordination notes, the Vineland-3 and BASC-3 PRQ (ages 2–18; initial and every 12 months), a rationale for requested hours, and the IEP/504 for school-based services — all on Humana's Behavior Analysis Authorization form (1023905FL0616).

### What does Humana pay non-par ABA providers in Florida?

Absent a letter of agreement, the lesser of the amount on Humana's authorization form or 100% of the Medicaid fee schedule — and the form sets that amount at 80% of the Medicaid Fee Schedule. The state's BA rates are the explicit reference point.

### Is Humana Healthy Horizons’s BA network open to new providers?

Not published as a yes or no. Florida law lets MMA plans “limit the providers in their networks based on credentials, quality indicators, and price” (s. 409.975(1), F.S.), so a plan may decline a new BA group. Ask Humana Healthy Horizons’s provider relations or contracting team whether it is adding BA groups in your region.

### What happens when a Humana Healthy Horizons member switches BA providers?

AHCA’s BA coverage policy, which every MMA plan must follow, says “a full assessment may be requested if there is a change in provider,” and a change in a practitioner’s credential (an RBT becoming a BCaBA) is not grounds for a reassessment. Expect the new agency to request its own assessment and treatment authorization; ask Humana Healthy Horizons how it closes the previous provider’s authorization.

### What is the payment turnaround for Humana Healthy Horizons ABA claims?

Florida law binds Humana Healthy Horizons as an MMA plan (§ 409.967(2)(j) → § 641.3155): pay or send a denial/contest notice within 20 days of an electronic claim (40 for paper), pay or deny within 90 days (120 for paper), and 12% interest on late payments. The statute also requires providers to file within 6 months of the date of service.

## Primary sources

1. [Humana Healthy Horizons in Florida — 2026 Provider Manual](https://assets.humana.com/is/content/humana/Provider_Handbookpdf)
2. [Humana Healthy Horizons FL — BA Informational Flyer (1025703FL0626)](https://assets.humana.com/is/content/humana/ABA_Informational_Flyer_AHCApdf)
3. [Humana FL — Behavior Analysis Authorization form (1023905FL0616)](https://assets.humana.com/is/content/humana/ABA_PA_Formpdf)
4. [Humana FL — ABA clinical toolkit](https://provider.humana.com/medicaid/florida-medicaid/aba-toolkit)
5. [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)
6. [Fla. Stat. § 409.975 (2026) — Managed care plan accountability (provider networks)](https://www.flsenate.gov/Laws/Statutes/2026/409.975)
7. [Fla. Stat. § 409.967 (2026) — Managed care plan accountability (prompt payment, (2)(j))](https://www.flsenate.gov/Laws/Statutes/2026/409.967)
8. [Fla. Stat. § 641.3155 (2026) — Prompt payment of claims](https://www.flsenate.gov/Laws/Statutes/2026/641.3155)
9. [Humana Healthy Horizons in Florida — Communications and Network Notices (2026, 2025 and archived notices)](https://provider.humana.com/medicaid/florida-medicaid/network-notices-communications)
10. [Humana Healthy Horizons in Florida — Prior Authorization page](https://provider.humana.com/medicaid/florida-medicaid/prior-authorization)
11. [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)
12. [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 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.