Molina Healthcare of Florida administers the Behavior Analysis benefit in-house on the AHCA criteria. It is also, from October 1, 2026, the operator of the Children's Medical Services Health Plan (see that guide). In July 2026 Molina published a 20-page BA authorization and documentation guide covering both lines. It is the most detailed of any Florida plan: exactly what a CDE must contain and who may perform it, a separate Vineland-3/BASC-3 behavior assessment, FBA/BIP data standards, weekly-hour authorizations and the reauthorization window. Two rules differ from the other plans: 97151 needs no prior authorization, and BA is authorized and billed against a weekly hour total.
Molina's guide is built around a complete first request. The CDE must be performed by a listed practitioner — including a licensed school psychologist, but not an unlicensed one — and must state a formal diagnosis. Scores from CARS or ADOS alone are not a diagnosis, and school accommodation letters are not enough. The Vineland-3 and BASC-3 PRQ go in as a separate behavior assessment with complete scoring reports, at the start and every 12 months; scores buried in a private CDE do not count. Every behavior-reduction goal needs an FBA/BIP with the child's own frequency, rate, duration and severity data. The request also needs a weekly schedule that matches the hours the child is actually available, the PCP's signed referral, and a transition plan from day one.[3][10][5]
Authorization mechanics: 97151 needs no prior authorization; 97153–97156 do, before services begin and at least every 180 days. Submit through Availity Essentials. Reauthorizations go in between 30 and 10 days before the end date. The guide gives MMA standard decisions as 4 business days, faster than the 7 calendar days in Molina's March 2026 manual and inside the AHCA contract's 5. Services are authorized and billed against a weekly hour total. A privately paid CDE is accepted if it meets the standard, and Molina may ask for a new CDE after a significant developmental change.[3][10][5]
Florida writes the claim clock for Medicaid health plans, Molina Healthcare of Florida 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.[2][7][8]
Molina’s own Florida Medicaid manual (9/9/2026): claims “must be submitted by the Provider to Molina within six (6) months after … the date of service for outpatient services,” and when Molina is not the primary payer, “within ninety (90) days after final determination by the primary payer.” “Corrected Claims must be sent within six months of Date of Service or most recent adjudicated date of the Claim,” through Availity or EDI (payer ID 51062). On processing the manual defers to the provider contract; absent another written schedule it says Molina “will process the claim for service within six months after receipt of Clean Claims,” and participating providers must enroll in EFT/ERA. No weekly cutoff or check-run day is published.[2][7][8]
The questions that decide whether a family can start with Molina Healthcare of Florida, and what they have to bring. Each maps onto something intake should ask on the first call.
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. The coverage policy binds every MMA plan and forbids more stringent service coverage limits than state policy, so Molina cannot narrow the window. Molina’s BA guide matches: “Molina covers Members under the age of 21 years requiring medically necessary BA services.”[5][3]
The CDE does not expire: per Molina’s July 2026 BA guide it “does not carry a defined expiration date for Medicaid/CMS Members,” but “Molina reserves the right to request a new CDE” after a significant change such as school entry, puberty or a change in diagnosis. The instrument clock is annual — complete Vineland-3 and BASC-3 PRQ scoring reports “at the initial authorization and at least every 12 months thereafter,” with updated findings for shorter periods — and authorizations renew at least every 180 days.[3][5]
Molina’s BA guide lists who may perform the CDE — a PCP in family practice, internal medicine or pediatrics; a board-certified or board-eligible developmental-behavioral, neurodevelopmental, pediatric-neurology or adult/child-psychiatry physician; a child psychologist (PhD or PsyD); a licensed school psychologist; or a multidisciplinary team led by one of them — and warns that “a CDE performed outside this practitioner list will not satisfy authorization requirements.” The state rule underneath: the referral comes from an independent physician or qualifying practitioner (PCP in family practice, internal medicine or pediatrics; a developmental-behavioral, neurodevelopmental, pediatric-neurology or adult/child-psychiatry specialist; or a child psychologist), and the CDE must be led by a licensed practitioner working within their medical, developmental or psychological scope of practice.[3][5]
The state pair: 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, with complete scoring reports attached to every prior-authorization request and re-administration every 12 months. Molina treats this behavior assessment as a separate document from the CDE — Vineland or BASC scores inside a privately obtained CDE do not replace it — and wants the CDE itself to state a formal diagnosis backed by standardized diagnostic testing (its examples: ADI-R, ADOS-2, CARS-2, DISCO).[5][3]
Required: a “signed referral from the member’s assigned Primary Care Provider (PCP)” that specifies ABA services, with the CDE, the Vineland-3/BASC-3 behavior assessment, a behavior plan covering the full requested period (up to 6 months), an FBA/BIP for any behavior-reduction goal, a weekly schedule by code and place of service, other services the child receives, caregiver-training goals, a supervision plan and a transition/discharge plan. Requests go through Availity Essentials; Molina’s Prior Authorization Code Lookup Tool shows code-level requirements. Utilization Management is at 855-322-4076.[3][4][5]
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. Molina’s July 2026 BA guide adds no expansion — only that “modifiers, including telehealth modifiers, should follow the current Medicaid Fee Schedule for the service and place of service rendered” — and it calls in-person evaluation best practice for the CDE.[5][3]
Molina’s July 2026 BA guide publishes a faster clock than its manual: standard BA decisions for MMA within “4 business days” (its CMS Plan BA training slide gives the same figure as 4 calendar days). The March 2026 manual still says “no later than contractual requirements or seven (7) calendar days,” and expedited “no later than contractual requirements or two (2) calendar days.” The contractual requirement is the AHCA clock of 5 days standard and 2 days expedited. Reauthorizations go in “as early as 30 days prior to the authorization end date, but no later than 10 days before the end date,” at least every 180 days; routine reauthorizations should not be sent as expedited. Molina does not retroactively authorize services that need PA.[3][11][10][12]
Molina’s manual: “Medicaid is always the payer of last resort … If third party liability can be established, Providers must bill the primary payer and submit a primary explanation of benefits (EOB) to Molina for secondary Claim processing.” Primary carrier payment information must be on the claim. Pay-and-chase exception: “Molina will pay claims for prenatal care and preventive pediatric care (EPSDT) and then seek reimbursement from third parties.” The manual does not say whether ABA claims count as EPSDT preventive care for this purpose. 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.[10][13]
Ask the plan: Molina Provider Services: whether an ABA claim for a child with commercial coverage can be paid first under the EPSDT exception, and whether Molina’s BA authorization is required when the commercial plan pays first.
Coverage decides whether Molina Healthcare of Florida pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
The state floor: supervision of BCaBAs and RBTs per the Council of Autism Service Providers practice standards, as specified in the supervision plan inside the approved behavior plan, which must name the authorized supervisors; Lead Analyst is a BCBA, FL-CBA or Ch. 490/491 licensee, a BCaBA works under a BCBA, and an RBT under a BCBA or BCaBA. Molina publishes no ratio of its own; its BA guide asks the supervision plan to name the “authorized supervisor(s): BCBA for RBTs and BCaBAs.”[5][3]
By the week. Molina’s July 2026 BA guide: “Services are authorized based on a weekly hour total. Providers must submit claims that do not exceed the number of hours authorized for that week.” Units follow the 8-minute rule — bill only services of 8 minutes or more, and a remainder of 8 minutes or more counts as one more unit. The state ceiling of up to 40 hours per week, with EPSDT above it and group treatment capped at six participants, sits underneath. Molina publishes no per-day unit table. At the claim level Molina’s 2026 manual applies NCCI edits “including procedure-to-procedure (PTP) bundling edits and Medically Unlikely Edits (MUE),” and “In the event a State benefit limit is more stringent/restrictive than a Federal MUE, Molina will apply the State benefit limit”; the public Medicaid MUE for 97153 is 32 units per claim line.[2][1][3][5]
The state rule, restated in Molina’s BA guide: “session notes must be 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 are signed by the Lead Analyst and the parent or guardian. Molina adds that maladaptive behaviors are “noted explicitly even if none occurred” and that templated or copied-forward notes “may be flagged during records review.”[5][3]
The state rule: a school-based request must include the IEP, or a 504 plan, or documentation naming the school and explaining that neither exists; 1:1 shadow, personal care assistance, companion and chaperone services are non-covered “regardless of activity or setting,” as are caregiver/childcare services and travel time; BA is non-covered on the same day as behavioral health overlay, therapeutic behavioral on-site, or therapeutic group care services.[5]
The state enrollment structure governs: a professional claim (837P / CMS-1500) under an individually enrolled rendering practitioner — Lead Analyst 392, BCaBA 391, RBT 390 — with 390s and 391s enrollable only as members of an enrolled BA group (393). Molina’s BA guide adds the claim mechanics: CMS-1500, codes, modifiers and units per Rule 59G-4.002, and submission through Availity Essentials (preferred), EDI payer ID 51062, or paper to PO Box 22812, Long Beach, CA 90801. It publishes no rule on rendering versus billing NPI beyond that.[5][3]
The state rule is the floor: 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. Molina’s BA guide restates only the supervisor/supervisee rule and does not address 97153 and 97155 overlapping when both practitioners are treating.[5]
Ask the plan: Molina provider services — ask whether 97155 pays alongside 97153 when analyst, technician and member are all face-to-face.
Six months from the date of service, per Molina’s September 2026 Florida Medicaid manual; 90 days after the primary payer’s final determination when Molina pays second. Corrected claims are due within six months of the date of service or the most recent adjudication.
Yes — it has administered the state Behavior Analysis benefit in-house since the February 2025 carve-in, for members under 21, on AHCA criteria: a PCP referral and a qualifying CDE, then prior authorization for treatment codes (97151 assessment is exempt).
In its Behavioral Analysis Services Authorization & Documentation Guide (effective July 2026), linked from Molina's Florida provider home page, and in the Prior Authorization Code Lookup Tool. The AHCA coverage policy sits underneath.
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 Molina’s provider relations or contracting team whether it is adding BA groups in your region.
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 Molina how it closes the previous provider’s authorization.
Florida law binds Molina Healthcare of Florida 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.
Molina's July 2026 guide requires a signed referral from the member's assigned PCP that specifies ABA services, with the CDE and Vineland-3/BASC-3 scoring reports. It also needs a behavior plan for the full period (up to six months), an FBA/BIP for any behavior-reduction goal, a weekly schedule by code and place of service, other services the child receives, caregiver-training goals, the supervision plan and a transition or discharge plan. Submit through Availity Essentials.
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.
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