External Review in Florida: Getting an Independent Decision on ABA

If your plan has turned down your internal appeal for ABA, you are not out of options. External review sends the dispute to an independent reviewer who does not work for your insurer, and if the reviewer sides with you, the plan must follow the decision. This guide walks Florida families through who qualifies, which external review route applies, the deadlines, expedited review, and what to send.

If you have not filed the internal appeal yet, start with how to appeal an ABA denial in Florida. This page picks up where that one ends.

What is external review, and when can I use it?

External review is an independent look at a denial after the plan's own appeal process is done. Under federal rules for most plans, it covers denials that involve medical judgment. HealthCare.gov lists:

• "Any denial that involves medical judgment where you or your provider may disagree with the health insurance plan," which includes medical necessity decisions such as denied or reduced ABA hours;
• "Any denial that involves a determination that a treatment is experimental or investigational"; and
• cancellation of coverage based on a claim that you gave false or incomplete information.

Denials based only on eligibility, such as a plan that simply excludes ABA as a benefit, are generally outside the federal external review process. Many ABA denials mix the two (for example, an exclusion applied because the plan judged ABA not medically necessary), so if you are unsure whether yours qualifies, ask the plan in writing or call the HealthCare.gov help line listed below.

You usually must finish the internal appeal first. There are two exceptions: urgent situations (below), and plans that fail to follow the internal appeal rules. Under federal rules, if a plan does not strictly follow them, "the claimant is deemed to have exhausted the internal claims and appeals process" and can go straight to external review, except for minor good-faith errors.

Which external review process applies in Florida?

Florida does not have a state external review process recognized by the federal government. A July 2026 CMS notice lists Florida among the states "without an applicable state external review process as determined by HHS." So the route depends on your type of plan:

Older "grandfathered" plans "may not include some rights and protections provided under the Affordable Care Act," according to HealthCare.gov. If your plan is grandfathered, your plan documents will say so and will explain any external review rights.

What are the deadlines?

• Your deadline to ask: within 4 months after you receive the final internal denial. Federal rules say that if there is no matching date four months later, the deadline is the first day of the fifth month, and a deadline on a weekend or federal holiday moves to the next business day.
• Preliminary review: the plan has five business days to check that your request is complete and eligible.
• Extra information: once the reviewer accepts the case, you get a notice and have ten business days to send more information.
• Standard decision: "no later than 45 days after the request was received."
• Expedited decision: "no later than 72 hours, or less, depending on the medical urgency of the case."

Illustrative timeline, not a promise: a family receives a final denial on March 3, files external review on March 20, receives an acceptance notice in late March, sends updated progress data within ten business days, and has a decision by early May.

A 2026 note: the HHS-administered process was temporarily unavailable in mid-2026 and reopened on July 31, 2026. CMS gave people whose deadline fell between July 1 and August 3 until October 2, 2026, to file. That extension has passed, so normal deadlines apply.

When can I ask for expedited external review?

Federal rules allow expedited external review in two situations:

1. At the same time as an expedited internal appeal, when the normal internal appeal timeline "would seriously jeopardize" the patient's life, health or ability to regain maximum function.
2. After a final internal denial, when the standard external review timeline would seriously jeopardize health.

Plans do not often treat ABA as urgent. If your child's safety is at risk, for example because of severe self-injury or aggression that ABA is addressing, ask your child's doctor to say so in writing and request expedited review. The reviewer decides whether it qualifies.

How do I file with the HHS-administered process?

If your denial letter points you to the HHS-administered process, HealthCare.gov lists these ways to file:

• Online: through the secure external review portal linked from the HealthCare.gov external review page.
• Email: ferp@maximus.com.
• Phone and fax: call 1-888-866-6205 for a request form, then fax it to 1-888-866-6190.
• Mail: MAXIMUS Federal Services, 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534.

There is no charge under the HHS-administered process. If your plan uses an IRO or another process, HealthCare.gov says any charge "can't be more than $25 per external review." If you want your child's doctor or another professional to file for you, use the authorized representative form available through the same site.

If your plan uses its own IRO, follow the instructions in the final denial letter exactly; it must tell you how to request external review.

What should I send with the request?

The reviewer starts with the plan's file, but your request is your chance to make the case. Include:

• the final denial letter and the original denial;
• a short cover letter: your child's name, member ID, what was denied, and why you disagree, in a few sentences;
• the diagnostic evaluation report;
• the BCBA's current assessment, treatment plan, goals, hours and fading plan;
• progress data and graphs, especially for a cut at reauthorization;
• standardized assessment scores the plan's criteria ask for;
• a letter of medical necessity from your child's physician (see letter of medical necessity); and
• the plan's own medical necessity criteria, with notes on how your child meets each one.

For a Florida fully insured large-group plan or group HMO, you can also point out that the state mandate requires ABA coverage for eligible children with autism and says coverage "may not be denied on the basis that provided services are habilitative in nature" (s. 627.6686(4)(c)).

What happens after the decision?

HealthCare.gov is direct: "Your insurer is required by law to accept the external reviewer's decision." If the reviewer overturns the denial, the plan must authorize or pay as the decision requires. Ask your provider to resubmit right away so services can start or resume. If the reviewer upholds the denial, ask your provider about a revised request with new data, consider self-pay or other coverage, and, for a self-funded ERISA plan, talk to a Florida attorney who handles benefit claims about your remaining options.

If the plan delays carrying out a decision, or you think it broke the rules along the way, you can complain to the right regulator; see filing an insurance complaint in Florida. For help with the process, HealthCare.gov's help line is 1-800-318-2596.

How Hope Center helps with external review

For children we serve, Hope Center for Behavior Change's BCBAs prepare the clinical documents a reviewer needs: the current assessment, treatment plan, progress data and a clear link between hours and goals. Our clinical director reviews every plan before it goes to insurance. You file the request, and we help you put the evidence together. If coverage is still denied, we can talk through self-pay with our sliding scale. Visit insurance at Hope Center, contact us or call 561-337-8865.