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Behavioral Analysis (BA) Services: CDE Documentation Requirements

Date: 10/14/25

Sunshine Health adheres to the AHCA Medicaid Behavioral Analysis Services Policy Handbook (PDF), including all outlined requirements.

In a previous Provider News Alert, we shared the Required Documents for Behavioral Analysis (BA) Providers. We are providing additional clarification to help reduce confusion, specifically regarding the Comprehensive Diagnostic Evaluation (CDE) documentation requirements.

A Comprehensive Diagnostic Evaluation (CDE) must follow national evidence-based practice standards. Each CDE must include:

  • A formal diagnosis made by the evaluating practitioner (not just a classification or score from tools like the Childhood Autism Rating Scale [CARS] or the Autism Diagnostic Observation Schedule [ADOS])
  • Background and presenting concerns
  • Diagnostic tools used
  • Treatment recommendations (Note: school accommodation recommendations alone are not sufficient.)

To initiate BA services, AHCA requires providers to submit a copy of the child’s CDE, along with all other required documentation for submitting prior authorization requests.

The CDE is the national practice standard necessary to diagnose autism as well as other developmental or behavioral disorders and indicate the most appropriate treatment(s) to address the child’s needs. A CDE is a thorough review and assessment of the child’s development and behavior. A CDE may be performed by a multidisciplinary team or individual practitioner. In either case, the CDE must be led by a licensed practitioner working within their scope of practice. The CDE must use evidence-based practice standards, methods and instruments, and the report must include assessment findings and treatment recommendations appropriate to the recipient.

The CDE must be completed by one of these licensed practitioners:

  • Primary care physician (PCP) specializing in family practice, internal medicine or a pediatrics specialty
  • Board-certified or board-eligible physician with a specialty in developmental behavioral pediatrics; neurodevelopmental pediatrics; pediatric neurology; or adult or child psychiatry
  • Psychologists

CDEs: Common Snags to Avoid:

  • Missing or unclear diagnosis: Every CDE must include a clear, evidence-based diagnostic conclusion made by the CDE licensed practitioner.
  • Insufficient background/history: Comprehensive developmental and medical history is essential.
  • Lack of direct observation or interviews: It is critical to observe the child and conduct interviews to understand their behaviors.
  • Limited understanding of the child: Evaluations should reflect meaningful engagement and insight into the child's needs and behaviors.
  • Overly brief reports: We encourage practitioners to be thorough and  ensure evaluations fully capture the child’s needs.
  • Virtual psychological testing: Virtual assessments may miss important behavioral cues; in-person interaction is often necessary to accurately assess dynamics. This is considered best practice for children.
  • Inappropriate BA referrals: Ensure BA services are clinically indicated; not all cases require this level of intervention.
  • Overlooking Individualized Education Programs (IEPs) and school data: Educational records like IEPs can provide valuable insight and should be reviewed.
  • Overlooking alternative treatments: Consider whether behavioral health (BH) therapy may be more appropriate than BA services in some cases.
  • Prioritize quality over quantity: Thorough, individualized evaluations provide the most meaningful support for members and are more impactful than a high volume of brief or incomplete assessments.

Reminder: CDEs do not expire for Medicaid recipients and are not required to be updated annually. If you are servicing one of our Ambetter Health members, then an Autism Spectrum Disorder (ASD) diagnosis is required and the CDE must be updated every five years.

Referrals:

The recipient must have been referred by an independent physician or practitioner qualified to assess and diagnose disorders related to functional impairment. The referral must be made and signed by one of the following practitioner types:

  • PCP specializing in family practice, internal medicine or a pediatrics specialty
  • Board-certified or board-eligible physician with a specialty in developmental behavioral pediatrics, neurodevelopmental pediatrics, pediatric neurology or adult or child psychiatry
  • Child Psychologist (PhD or PsyD)

References:

Questions?

Sunshine Health has a wealth of resources available to help answer your questions and address your concerns:

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