A denial letter for your child's ABA can feel like a closed door. It usually is not. Many ABA denials are about missing paperwork, a disagreement over hours, or a rule the plan applied without looking closely at your child. Federal and Florida law give you the right to ask the plan to look again, and then to ask an independent reviewer. This guide gives you the clocks, the steps, a sample letter and the evidence that tends to matter.
One note before you start: this is general information. Your plan's denial notice tells you the exact deadlines and addresses for your plan, and those control. For a legal dispute, talk to a Florida attorney.
What should I do in the first few days after a denial?
- Read the denial notice closely. Note the date, the reason, and whether it is a full denial, a partial approval (fewer hours than requested) or a denial of continued care.
- Ask for the criteria. Request, in writing, the specific plan provision and the medical necessity guideline the plan used, plus your claim file. Plans must give these to you free of charge on request.
- Tell your ABA provider. The BCBA can often request a peer-to-peer review, a phone call with the plan's reviewer, which sometimes resolves a denial quickly.
- Find out what kind of plan you have. The appeal route depends on it. See fully insured vs self-funded plans.
- Write the deadline on your calendar. Count from the date you received the notice.
What are the deadlines for an ABA appeal?
| Step | Your deadline | Plan or reviewer's deadline |
|---|---|---|
| Prior authorization decision (initial request) | None | Generally 15 days for a pre-service request under federal rules, with one extension allowed |
| Internal appeal | At least 180 days from the denial notice | 30 days for a service not yet received; 60 days for a service already received |
| Urgent internal appeal | As soon as possible | No more than 72 hours under the federal claims rule for employer plans |
| External review | Within 4 months of the final internal denial | 45 days standard; 72 hours or less if expedited |
| Florida HMO grievance | Per your HMO contract | 60 days (90 if out-of-area information is needed); 72 hours if urgent |
A note on urgency: HealthCare.gov describes urgent appeals as decided within 4 business days, while the federal claims regulation for employer plans sets 72 hours. Plans often do not treat ABA as urgent; UMR's ABA form, for example, says "ABA cases are not considered Urgent or Expedited." If a delay could seriously harm your child, ask the child's doctor to say so in writing and request an expedited review anyway.
How do I file the internal appeal?
The internal appeal asks the plan to reconsider. Follow the instructions in the denial notice: some plans have a form, and all accept a written letter. Send it in a way you can prove, such as the plan's portal with a confirmation, fax with a confirmation sheet, or certified mail. Keep copies of everything.
Sample appeal letter
Adapt this to your situation. Keep it factual and short; the attachments do the heavy lifting.
[Date]
[Plan name], Appeals Department
[Address or fax from the denial notice]
Re: Appeal of denial of applied behavior analysis (ABA)
Member: [child's name], date of birth [date], member ID [number]
Claim or reference number: [number], denial dated [date]
I am writing to appeal the denial of ABA services for my child, who has a diagnosis of autism spectrum disorder (F84.0). The denial states [quote the reason]. I disagree for these reasons:
1. [For example: the treatment plan shows measurable goals and progress data, attached.]
2. [For example: my child's doctor recommends ABA as medically necessary, letter attached.]
3. [If a fully insured Florida large-group plan or HMO: Florida law, s. 627.6686 (or 641.31098), requires coverage of ABA for autism for eligible individuals and says coverage may not be denied because services are habilitative.]
Please also send me, free of charge, the plan language and the medical necessity criteria used, and all documents relevant to this claim. If this appeal is denied, please tell me how to request external review.
Sincerely, [your name, phone, email]
Evidence to attach
- the denial letter;
- the diagnostic evaluation report (an IEP alone is usually not enough);
- a letter of medical necessity from your child's physician or diagnosing clinician; see letter of medical necessity;
- the BCBA's assessment and treatment plan with measurable goals, hours and parent training goals;
- progress data and graphs, for a continued-care denial;
- standardized assessment scores (for example Vineland-3) if the plan's criteria ask for them;
- notes on safety concerns, school reports or other therapists' notes that show need; and
- a short log of what happens if services stop or drop.
Match your evidence to the reason given. If the plan said "no progress," send data. If it said "not medically necessary," show how your child meets each criterion in the plan's own guideline.
What is external review, and how does it work in Florida?
If the plan upholds its denial, you can ask an independent reviewer to decide. Under federal rules, you have 4 months after the final denial to ask. The reviewer must decide within 45 days, or within 72 hours or less for an expedited case, and "Your insurer is required by law to accept the external reviewer's decision."
Florida does not have an HHS-recognized state external review process. A July 2026 CMS notice lists Florida among the states "without an applicable state external review process as determined by HHS." So for insured plans in Florida, external review runs through the federal HHS-administered process (the contractor is MAXIMUS Federal Services) or through an accredited independent review organization the plan contracts with. Under the HHS-administered process there is no fee. HealthCare.gov lists these ways to request it:
- online through the federal external review portal (linked from HealthCare.gov);
- by email to ferp@maximus.com;
- by calling 1-888-866-6205 for a form, then faxing it to 1-888-866-6190; or
- by mail to MAXIMUS Federal Services in Pittsford, New York, at the address given on HealthCare.gov.
Self-funded employer plans also must offer external review under federal rules, usually through independent review organizations the plan contracts with. Your final denial letter must explain how to request it.
A 2026 note: the HHS-administered process was temporarily unavailable in mid-2026 and reopened July 31, 2026. CMS extended deadlines that fell in that gap to October 2, 2026, and that extension has now passed. More detail in external review in Florida.
What if my child is in a Florida HMO?
Florida HMOs must also follow the state grievance law, s. 641.511. HMOs must resolve grievances within 60 days (90 days if information from outside the service area is needed). For urgent grievances, the decision must come "in no event more than 72 hours after receipt." There is an important protection for ongoing ABA: in an expedited review of a concurrent review decision, such as a cut to hours your child already receives, "the service shall be continued without liability to the subscriber until the subscriber has been notified" of the decision. You can also request review by an internal review panel within 30 days of the final adverse decision.
Who else can help with an ABA denial?
- Fully insured plans: Florida Department of Financial Services Insurance Consumer Helpline, 1-877-693-5236. See filing a DFS complaint.
- Self-funded employer plans: U.S. Department of Labor, Employee Benefits Security Administration, 1-866-444-3272.
- Federal employee plans: after the carrier's reconsideration, the Office of Personnel Management.
- TRICARE: follow the appeal instructions in your TRICARE notice; East Region customer service is 1-800-444-5445.
If the denial looks like the plan treats autism care more strictly than medical care, for example a blanket exclusion or extra paperwork that medical services do not face, read mental health parity and ABA denials.
How Hope Center helps when a plan says no
When a plan denies or cuts ABA for a child we serve, our BCBAs can request a peer-to-peer review, update the treatment plan and data, and prepare the clinical documents for your appeal. Our clinical director reviews every treatment plan before it goes to insurance, which helps prevent avoidable denials in the first place. If you are not yet with us and have a denial in hand, we can review your benefits for free and talk through options, including self-pay with a sliding scale while an appeal is pending. See insurance at Hope Center, contact us for a free consultation or call 561-337-8865.