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 form.

Contracted providers should attempt the following prior to submitting an Exception Request:

Refer any Sunshine Health/CMS members to an in-network practitioner
Engage Sunshine Health/CMS Case Management that can assist members/families locating and coordinating with another in-network provider
Contact Sunshine Health Customer Service for list of in-network BA providers
Utilize the Find a Provider Tool to identify additional in-network providers

Before you proceed, please take a moment to review the information provided below. This will help ensure a successful submission and expedite the addition of your new provider.

Important Reminders

The justification letter must be prepared on official letterhead and signed by a representative of the provider organization. Justification letters written by a member’s caregiver will not be accepted, as this form is meant to be completed fully by a contracted provider.
If you do not have the capacity to accept new referrals with your existing staff, we kindly ask that you please follow the guidance outlined on the Exception Request form. Initial assessments should not be conducted unless and until an enrollment exception has been formally approved. This guidance is supported by the BACB Ethics Code for Behavior Analysts (PDF), (see 3.03 ,1.05, 1.06).
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), (see 3.15, 1.03, 3.06, 3.12).
SCHOOL LIAISON PROGRAM: Did you know that our members may be able to get extra help with school. Our MMA/CW/SMI & HIV School Liaisons can work with parents and their children’s school to request an evaluation. Details about Sunshine Health's School Liaison Program:
Providers are reminded of the Specific Non-Covered Criteria as outlined in Section 5.2 of the Florida Medicaid Behavioral Analysis Coverage Policy (PDF).

Contracted Provider Information

Provider (Group) Name *

TIN (Tax Identification Number) * Please no dashes "-"

Group National Provider Identifier (GNPI) *

Region *

Servicing County *

Name of Practitioner Exception Requested * Please no numbers

Name of Practitioner Exception Certification Type (BCBA, BCaBA or RBT) *

Exception Practitioner NPI *

Exception Practitioner Supervisor Name *

Reason for Exception Request (Select all that apply) * Provider serves specialized populations, such as deaf/hard of hearing individuals/American Sign Language (ASL) Provider specializes in complex medical needs Practitioner on Medical/Maternity Leave Significant waitlists No availability

Impacted Member Information

Number of Impacted Members *

Member Full Name *

Member ID *

Diagnosis *

Anticipated Member Start Date of Service (DOS) *

Member’s City *

Member’s County *

Request Submitted By

Submitter Name *

Submitter Title *

Submitter Email *

Submitter Phone *

Date Submitted *

Required Attachments

LOAP (Excel spreadsheet) *

Case details/justification (PDF document) *

Clinical supporting documentation (PDF document) *

Other

Please note all requests will be reviewed by Sunshine Health within 30 days to determine if an exception needs to be made. The goal is to ensure members are serviced by in-network providers who have been through the credentialing and onboarding process.