Almost every health plan that covers ABA wants to approve it in advance. That step, prior authorization, is where many families feel stuck: the assessment is done, everyone is ready, and the plan has not answered. This guide lays out the authorization path step by step, the documents plans ask for, the decision clocks that apply, Florida's prior authorization form law, and the bottlenecks you can actually control.
What is prior authorization for ABA?
Prior authorization (also called pre-authorization or pre-certification) is the plan's advance approval of a service. For ABA, the provider sends the plan the diagnosis, assessment and treatment plan, and asks for a set number of units of each service for a period, often about six months. The plan reviews the request against its medical necessity criteria and approves it, approves part of it, asks for more information or denies it.
Authorization is not a promise of payment for everything. Your plan can still apply deductibles, copays and other terms, and an approval is usually limited to the units, dates and provider listed. Florida's autism mandate expressly allows "utilization review of health care services, including the review of medical necessity" (s. 627.6686(4)(d)).
What are the steps, from diagnosis to first session?
- Diagnosis. Plans usually want a full diagnostic report from a qualified clinician. UMR, for example, says "IEPs and school evaluations are NOT acceptable as the sole proof of diagnosis," and asks for current documentation if the report is more than 4 years old.
- Benefits check. The provider confirms ABA is covered, which authorizations are needed and your cost-sharing; see what a benefits check covers.
- Assessment authorization, if required. Some plans authorize the assessment separately. Evernorth's ABA form, for example, says assessment codes 97151, 97152 and 0362T "no longer require prior authorization" for standard requests, while the ABA level of care still does. Other plans differ.
- Assessment and treatment plan. The BCBA assesses your child and writes measurable goals, hours for each service, parent training goals and a transition or discharge plan.
- Physician sign-off, if required. In Florida mandate plans, coverage is limited to treatment "prescribed by the insured's treating physician in accordance with a treatment plan," and the plan must include "the signature of the treating physician" (s. 627.6686(4)(a), (7)). See physician prescriptions and ABA treatment plans.
- Submission. The provider sends the request with the required attachments.
- Decision. Approval, partial approval, a request for more information, or denial.
- Scheduling and start. Services begin once the approval is in hand.
What do plans usually ask for?
| Document | Examples of what plans say |
|---|---|
| Diagnostic report | Cigna asks for the diagnostician's name, credentials, licensure and date of diagnosis. UMR does not accept an IEP or school evaluation alone. |
| Standardized assessment | Aetna asks for impairment on a standardized scale within the past 12 months. Cigna asks for a current instrument completed within 60 days before treatment starts. |
| Treatment plan | Measurable goals, baselines, hours per service, generalization and fading plans, coordination with school and other providers (Cigna, UMR). |
| Parent training goals | UMR lists parent training goals as required; Aetna requires caregiver engagement. |
| Physician order or signature | Required by Florida's mandate for plans it covers; other plans vary. |
| Insurance details | Member ID, group number and any secondary coverage. |
For a family-side list, see documents to start ABA.
How long does the plan have to decide?
It depends on the type of plan.
- Employer plans (ERISA), fully insured or self-funded. For a pre-service request, the federal claims rule gives the plan "not later than 15 days after receipt of the claim," with one extension of up to 15 days for matters beyond its control. If the plan needs information from you or the provider, you get "at least 45 days" to supply it, and the clock pauses. Urgent requests must be decided within 72 hours.
- Florida HMOs. HMOs follow their contract and s. 641.511 for grievances, with the federal rule as the minimum for employer groups.
- TRICARE. A referral and pre-authorization are required for all ABA. Each authorization covers six months, and a new referral from the diagnosing provider is needed every two years. See the TRICARE ACD guide.
- Medicaid and Medicare Advantage plans. Under a federal rule (CMS-0057-F), from January 1, 2026, these plans must decide standard requests within 7 calendar days and expedited ones within 72 hours. That rule does not apply to employer plans, and its decision clocks do not apply to Marketplace plans.
Many plans decide faster than these outer limits. If a plan goes past them, ask in writing for the status and the reason, and see where to file a complaint.
Does Florida law limit prior authorization paperwork?
Partly. Section 627.42392, Florida Statutes, says a health insurer (including an HMO or Medicaid managed care plan) that does not offer an electronic prior authorization process to its contracted providers must "only use the prior authorization form that has been approved by the Financial Services Commission." That form "may not exceed two pages in length, excluding any instructions or guiding documentation." The law was last changed in 2017.
The two-page limit applies to the form, not to the clinical attachments, and plans with electronic portals are outside it. Self-funded employer plans are governed by federal law, not this statute.
No new prior authorization law passed in 2026. Bills to overhaul Florida's prior authorization rules (SB 1130 / HB 1015) and to create a claim-dispute program for denied requests (SB 1198 / HB 1023) all died in committee on March 13, 2026.
What slows authorization down, and what can I control?
In our experience at Hope Center, delays usually come from paperwork, and much of it is in a family's hands:
- Missing diagnostic report. Get the full report, not a summary or a letter, from the clinician who diagnosed your child.
- Insurance card details. Send clear photos of both sides of every card, including any secondary plan.
- Unsigned forms. Return intake forms and the treatment plan signature quickly.
- Physician signature. If your plan needs one, ask your child's doctor's office how they handle ABA plan signatures and how long it takes.
- Assessment scheduling. Book the assessment sessions as early as you can.
- Questionnaires. Complete parent questionnaires promptly; plans increasingly require standardized parent-report scores.
Things you cannot control, such as plan review time, still move faster when the request is complete the first time. If the plan asks for more information, ask your provider what is missing and whether you can help.
A quick script for checking status
"Hello, I am calling about a prior authorization request for applied behavior analysis for my child, [name], member ID [number]. The provider is [provider name], and the request was submitted on [date]. Can you tell me its status, whether anything is missing, and the date by which a decision is due? May I have a reference number for this call?"
How Hope Center handles authorization
At Hope Center for Behavior Change, the path is: intake documents, a free benefits check, an initial assessment of 2 to 4 hours in one or two sessions at home or in the center, up to two weeks to write the plan, your signature, then submission to your insurer. Our clinical director reviews every plan before it goes to insurance. Once the plan is approved, services usually start within 3 to 5 business days, and there is no waitlist. From first call to first session can be as little as three weeks; slow paperwork can stretch it to months. See the Hope Center intake timeline, visit insurance at Hope Center, contact us or call 561-337-8865.