Contracted Provider Behavior Analysis Network Exception Request Form
Please note: This exception request form is available only to contracted providers who are requesting to add a practitioner to their existing contract. Out of Network providers interested in joining Sunshine Health's network must complete the Become a Provider web form.
Contracted providers should attempt the following prior to submitting an Exception Request:
- Refer any Sunshine Health members to an in-network practitioner.
- Engage Sunshine Health Case Management to assist members and their caretakers/families/guardians to locate and coordinate with another in-network provider.
- Contact Sunshine Health Customer Service for a list of in-network Behavior Analysis (BA) providers.
- Utilize the Find a Provider Tool to identify additional in-network providers.
New Provider Justification Letter
Once a provider has followed the guidance above, they must submit a justification letter to the health plan that clearly explains the need for an exception to the current BA enrollment pause to register a new provider to treat the member.
The letter must follow these guidelines:
- It must be prepared by the member’s contracted provider, not their caregiver/guardian/family.
- It must include relevant details about the member’s case.
- It must explain why an exception must be made for the specified practitioner.
- It must explain the specific practitioner is needed to care for the member.
- It must be prepared on the contracted provider’s official letterhead.
New Provider: Submitting New Authorization Requests
When the health plan approves a new provider to care for a member, that provider must follow this guidance to obtain a new authorization to treat their new patient. The old authorization, obtained by the prior provider, is no longer valid.
The new provider must:
- Follow the standard initial authorization request process, requesting an initial 24 units before requesting treatment codes.
- Complete and submit the following:
- Their own assessment and treatment plan
- A new assessment of the child’s current functioning, as is required
- New, fully updated core instruments (Vineland and BASC)
- A completed Behavior Analysis (BA): Change of Provider Form (PDF)
- A completed and signed PCP Acknowledgement and Care Coordination Form (PDF)
- Provide their own clinical documentation. Sunshine Health cannot utilize clinical documentation completed by a previous provider to support a new authorization request.
- Complete and submit their own clinical documentation using new, current data, as required.
For more information regarding required documentation, please visit: Behavior Analysis (BA) Quick Reference Guide (QRG)
Before you proceed, please take a moment to review the information below. This will help ensure a successful submission and expedite addition of the new practitioner.
Important Reminders
- If you do not have the capacity to accept new referrals with your existing staff, we ask that you please follow the guidance outlined above. An authorization should not be requested and the initial assessments should not be conducted unless and until an enrollment exception has been formally approved. This guidance is supported by BACB Ethics Code for Behavior Analysts (PDF).
- DISCHARGE PLANNING AND TITRATION: Discharge planning and titrating down BA services ensures ethical practice, promotes independence and maintenance of skills, supports caregivers, uses resources responsibly, and leads to more durable and meaningful outcomes for clients as supported by the BACB Ethics Code for Behavior Analysts (PDF).
- SCHOOL LIAISON PROGRAM: Did you know that our members may be able to get extra help with school? Our School Specialists can work with parents and their children’s school to request an evaluation. Select the following links to learn more about Sunshine Health's School Specialist Programs:
- Providers are reminded of the Specific Non-Covered Criteria as outlined in Section 5.2 of the Florida Medicaid Behavioral Analysis Coverage Policy (PDF).