Guidance for CMS Title 21: Prior Authorization Required for New ABA CPT Codes

Date: 07/26/22

Fort Lauderdale, Florida

Effective Aug. 1, 2022, the Agency for Health Care Administration (AHCA) is converting the Behavior Analysis fee schedule from its current HCPCS code structure to the Behavior Analysis CPT code structure.

The updated 2022 fee schedules are available on AHCA’s reimbursement schedule page, Rule 59G-4.002, Provider Reimbursement Schedules and Billing Codes. Download the 2022 BA fee schedule (PDF).

As a result of this change, all CPT codes for ABA services provided to CMS Title 21 members will require prior authorization from Sunshine Health. Prior authorization requests for CMS Title 21 members can be submitted via the Secure Provider Portal. Authorization requests for CMS Title 19 and all other Medicaid members should continue to go through EQHealth.

Sunshine Health will provide a grace period for HCPCS codes that did not previously require prior authorization (H0031, H0032, H2019). Providers have until Sept. 1 to submit prior authorization for these services. See corresponding CPT codes below:

If you have a prior authorization with an end date past Aug. 1, 2022, no new authorization is required until the current authorization expires. Sunshine Health will crosswalk the HCPCS codes to CPT codes under the existing authorization. No action is required on your part.

Thank you for your continued participation with the Children’s Medical Services (CMS) Health Plan. If you have questions about this notice, please call Sunshine Health Provider Services at 1-844-477-8313.

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