---
title: Molina Healthcare of Florida ABA / BA coverage (MMA plan).
url: "https://carelu.com/payers/molina-healthcare-florida"
markdown_url: "https://carelu.com/payers/molina-healthcare-florida.md"
state: FL (Florida)
payer: Molina Healthcare of Florida
kind: Medicaid managed care plan (MCO)
parent_program: Florida Medicaid (AHCA)
description: "How Molina Healthcare of Florida administers the Medicaid Behavior Analysis benefit — in-house UM on state criteria, its July 2026 BA authorization and documentation guide, weekly-hour authorizations, and the 97151 PA exemption."
last_reviewed: October 2026
vob_data_updated: 2026-10-15
---

# Molina Healthcare of Florida ABA / BA coverage (MMA plan).

_Payer Guide · Molina Healthcare (FL) · Last updated October 2026 · 9 primary sources_

> In-house BA on state criteria; detailed July 2026 BA guide, weekly-hour auths, 97151 without PA.

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.

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**: Not for 97151 — Molina's July 2026 BA guide says “Code 97151 (Behavior Identification Assessment) does not require prior authorization”; confirm in the PA Code Lookup Tool [3]
- **Prior auth for treatment**: Required — 97153, 97154, 97155 and 97156 need PA before services begin and at each reauthorization (at least every 180 days), via Availity Essentials [3][5]
- **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 (Molina), in-house UM; also runs the CMS Plan from 10/1/2026
- **Clinical rules:** AHCA BA Coverage Policy, plus Molina's July 2026 BA authorization & documentation guide
- **Prior auth:** Availity Essentials; 97151 exempt, 97153–97156 require PA; UM 855-322-4076
- **Decisions:** Standard 4 business days (BA guide); expedited 2 calendar days; reauth 30–10 days before end
- **Units:** Authorized as a weekly hour total — claims may not exceed the week
- **Claims:** CMS-1500 via Availity or EDI payer ID 51062

## What Molina's BA guide requires

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]

## How fast must Molina Healthcare of Florida pay an ABA claim?

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]

## Intake gates

The questions that decide whether a family can start with Molina Healthcare of 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. 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]
- **Diagnosis recency**: 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]
- **Who may diagnose**: 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]
- **Diagnostic tools required**: 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]
- **Referral required?**: 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]
- **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. 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]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: 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.

## Delivery and billing rules

Coverage decides whether Molina Healthcare of 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, 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]
- **Daily limits / MUEs**: 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]
- **Session-note signature**: 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]
- **Place of service**: 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]
- **Bill as provider**: 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]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: 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.

## What intake should collect for Molina Healthcare of Florida

- **Referral + order + CDE:** The state eligibility gate applies; no autism diagnosis required.
- **Vineland-3 & BASC-3 scoring reports:** The state documentation stack applies to Molina requests.
- **PCP referral + qualifying CDE:** A signed referral from the assigned PCP that names ABA, and a CDE from a listed practitioner that states a formal diagnosis.
- **Weekly availability:** Molina authorizes weekly hours and checks them against the child's real schedule — capture school hours, other therapies and family availability at intake.

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

## Verification of benefits (VOB) data

How Molina Healthcare of Florida ABA benefits route and read on an eligibility check. Data last updated 2026-10-15.

### EDI routing

- **Payer ID (pVerify):** 00300
- **Payer ID (Availity):** 51062
- **Supports 270/271 eligibility:** Yes
- **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 | Not required — Molina's BA guide lists 97151 as the one BA code without prior authorization (confirm in the PA Code Lookup Tool). | 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. Molina's July 2026 BA guide exempts this code: "Code 97151 (Behavior Identification Assessment) does not require prior authorization. All other BA service codes listed above require prior authorization before services begin." Run the code through Molina's Prior Authorization Code Lookup Tool before relying on it. These are the statewide AHCA BA Coverage Policy mechanics, binding on Molina Healthcare of Florida per the policy's plan-compliance clause (§1.2); Molina Healthcare of 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 Molina Healthcare of Florida provider relations before quoting a family.
- **97152, 97156, 97158:** These are the statewide AHCA BA Coverage Policy mechanics, binding on Molina Healthcare of Florida per the policy's plan-compliance clause (§1.2); Molina Healthcare of 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 Molina Healthcare of 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 Molina Healthcare of Florida per the policy's plan-compliance clause (§1.2); Molina Healthcare of 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 Molina Healthcare of 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 Molina Healthcare of Florida per the policy's plan-compliance clause (§1.2); Molina Healthcare of 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 Molina Healthcare of 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 Molina Healthcare of Florida per the policy's plan-compliance clause (§1.2); Molina Healthcare of 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 Molina Healthcare of 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. Molina's own 213-page Medicaid Provider Handbook contains zero mentions of Behavior Analysis or any BA code. Molina's July 2026 BA guide (read in full 2026-09-27) lists only 97151 and 97153-97156 in its code table — 97157 does not appear there either. These are the statewide AHCA BA Coverage Policy mechanics, binding on Molina Healthcare of Florida per the policy's plan-compliance clause (§1.2); Molina Healthcare of 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 Molina Healthcare of 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 Molina Healthcare of Florida per the policy's plan-compliance clause (§1.2); Molina Healthcare of 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 Molina Healthcare of 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 Molina Healthcare of Florida per the policy's plan-compliance clause (§1.2); Molina Healthcare of 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 Molina Healthcare of Florida provider relations before quoting a family.

### Medicaid rates

Source: AHCA Behavior Analysis Fee Schedule (2025 and 2026 — rates identical across both years). No Molina-specific rate schedule is publicly posted — MCOs must not impose limits more stringent than this state schedule, which serves as the reference baseline (AHCA BA Coverage Policy §1.2). Effective 2025-01-01.

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | $19.05 | 15min | TS: $19.05 (reassessment; same rate, 18-unit cap vs. 24 for the initial assessment) |
| 97152 | $12.19 | 15min | — |
| 97153 | $12.26 | 15min | XP: Not reimbursed (concurrent-supervision supervisee line) |
| 97154 | $7.58 (2 clients, UN) | 15min | UN: $7.58 (2 clients); UP: $7.08 (3); UQ: $6.58 (4); UR: $6.08 (5); US: $5.58 (6) |
| 97155 | $19.17 (Lead Analyst) | 15min | HN: $15.37 (BCaBA); XP: Not reimbursed (concurrent-supervision supervisee line) |
| 97156 | $19.05 (Lead Analyst) | 15min | GT: $19.05 (telemedicine — same rate, capped at 2 hrs/week); HN: $15.24 (BCaBA) |
| 97157 | Not on the AHCA fee schedule (2025 or 2026) — not confirmed reimbursable under Florida Medicaid BA. | 15min | — |
| 97158 | $9.58 (2 clients, UN) | 15min | UN: $9.58 (2 clients); UP: $9.08 (3); UQ: $8.58 (4); UR: $8.08 (5); US: $7.58 (6) |
| 0362T | $12.19 | 15min | — |
| 0373T | $12.19 | 15min | — |

### Contacts

- **Benefits by phone:** Yes
- **Provider services phone:** (855) 322-4076
- **Hours:** Monday–Friday, 8:00 a.m.–7:00 p.m.
- **Portal:** [Molina Healthcare of Florida Provider Portal](https://provider.molinahealthcare.com/provider/login)

Questions to ask on a verification call:

- What payer ID should we use for Change Healthcare eligibility checks, and do you support real-time 270/271 on Availity ID 51062?
- 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://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://www.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/fl/medicaid/3-18-26-MHFL-Medicaid-Provider-Handbook-508.ashx (accessed 2026-07-23)
- 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://www.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/fl/medicaid/08-07-26-MHFL-Comprehensive-BA-QRG-508.ashx (accessed 2026-09-27)
- https://ahca.myflorida.com/content/download/28096/file/2026%20BA%20Fee%20Schedule.pdf (accessed 2026-09-27)
- https://www.molinahealthcare.com/providers/fl/medicaid/contacts/contact_info.aspx (accessed 2026-07-23)
- https://www.molinahealthcare.com/-/media/Project/PWS/Healthcare/PDF/PDF/Providers/FL/Manuals/09-09-26-MHFL-Molina-Provider-Handbook-CMS-and-SMMC-508.pdf (accessed 2026-10-14)

## Common questions

### What is Molina Healthcare of Florida’s timely filing limit for ABA claims?

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.

### Does Molina Healthcare of Florida cover ABA?

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).

### Where are Molina's Florida BA rules published?

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.

### Is Molina’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 Molina’s provider relations or contracting team whether it is adding BA groups in your region.

### What happens when a Molina 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 Molina how it closes the previous provider’s authorization.

### What is the payment turnaround for Molina Healthcare of Florida ABA claims?

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.

### What documents does Molina Healthcare of Florida need at intake for ABA?

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.

## Primary sources

1. [CMS — Medicaid NCCI Edit Files (practitioner MUE table effective 10/1/2026)](https://www.cms.gov/medicare/coding-billing/ncci-medicaid/medicaid-ncci-edit-files)
2. [Molina Healthcare of Florida — Medicaid Provider Manual for Molina Medicaid and CMS Plan members (9/9/2026)](https://www.molinahealthcare.com/-/media/Project/PWS/Healthcare/PDF/PDF/Providers/FL/Manuals/09-09-26-MHFL-Molina-Provider-Handbook-CMS-and-SMMC-508.pdf)
3. [Molina Healthcare of Florida — Behavioral Analysis Services: Authorization & Documentation Guide (Comprehensive BA QRG, effective July 2026)](https://www.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/fl/medicaid/08-07-26-MHFL-Comprehensive-BA-QRG-508.ashx)
4. [Molina FL — BA Quick Reference Guide 2026 (revised 2/5/2026)](https://www.molinahealthcare.com/providers/fl/medicaid/comm/-/media/D0605825716B47F8819AD3B554626A86.ashx)
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. [Molina Healthcare of Florida — Provider Communications (newsletters and notices by year)](https://www.molinahealthcare.com/providers/fl/communications)
10. [Molina Healthcare of Florida — Medicaid Provider Manual (3/18/2026)](https://www.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/fl/medicaid/3-18-26-MHFL-Medicaid-Provider-Handbook-508.ashx)
11. [CMS Plan by Molina Healthcare — Provider Orientation: Behavior Analysis Services (August 2026)](https://www.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/fl/medicaid/09-03-26-MHFL-CMS-Plan-BA-Training-508.pdf)
12. [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)
13. [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.