Your child's sessions are going well, and then a bill arrives for hundreds of hours you thought insurance was paying for. Or your provider tells you the plan has not paid in months. Claim problems are stressful, but most have a clear cause and a clear owner. This guide explains the usual causes, the Florida rules that protect you while a claim is sorted out, and who to call, in what order.
This is general information. Your plan's documents and the notices it sends you control the details for your plan.
Why do ABA claims get stuck or denied?
ABA is billed in many small units, often every week, under several codes. That creates more chances for something to go wrong. The common causes:
- Authorization problems. Sessions billed after the authorization period ended, or more units than approved. ABA is usually authorized in periods of about six months. See reauthorization every six months.
- Eligibility changes. A new plan year, a job change, a new member ID card, or a dependent who aged off a plan.
- Coordination of benefits. If your child has two plans, the plans must agree which pays first. A missing coordination-of-benefits questionnaire is a frequent reason claims stop. See two insurance plans and ABA.
- Coding or paperwork errors. A wrong code, missing modifier or mismatched provider identifier.
- Network or credentialing issues. The provider, or the individual clinician, is not loaded as in-network with your specific plan.
- Coverage disputes. The plan treats a service as educational, or as overlapping with another therapy at the same time. Several payer policies exclude those.
- The deductible reset. In January (or whenever your plan year starts), your share may jump until you meet the new deductible. That is not an error, but it often feels like one.
How fast must a Florida insurer pay an ABA claim?
Florida's prompt-pay laws set deadlines for fully insured health insurers (Fla. Stat. 627.6131) and HMOs (641.3155). These rules run between the insurer and the provider, but they tell you how long a stuck claim should take.
| Step | Electronic claims | Paper claims |
|---|---|---|
| Pay, or tell the provider the claim is denied or contested | Within 20 days | Within 40 days |
| Provider sends any extra information requested | Within 35 days of the request | Within 35 days of the request |
| Claim must be paid or denied | Within 90 days | Within 120 days |
| If not paid or denied by this day, the insurer has "an uncontestable obligation to pay" | Day 120 | Day 140 |
Overdue payments bear "simple interest of 12 percent per year," which is "payable with the payment of the claim." Two more rules explain some late surprises: an insurer may not retroactively deny a claim because of ineligibility "more than 1 year after the date of payment" (627.6131(11); 641.3155(10) for HMOs), and insurers can seek overpayments back from providers, generally within 30 months. Either can lead a provider to contact you about an older claim.
These state rules apply to major medical policies from Florida-licensed insurers, including PPO and EPO policies (627.6131(15)), and to HMOs. They do not cover self-funded employer plans. For those, the federal claims rule applies: a decision on a claim for care you already received is due within 30 days, with one 15-day extension allowed if the plan tells you before the 30 days end.
Can the provider bill me while the claim is in dispute?
In many cases, not yet. Under Fla. Stat. 627.6131(9), a provider "may not collect or attempt to collect money from, maintain any action at law against, or report to a credit agency an insured" for covered services when the insurer contested or denied the provider's claim. That protection applies while the claim is pending and through the insurer's internal dispute process, "not to exceed 60 days" from the denial. It does not stop the provider from collecting your usual copays, coinsurance and deductibles. HMOs have the same rule in 641.3155(8), and it applies whether or not the provider is under contract with the plan.
Florida HMO members have one more protection. If the HMO is liable for a service, for example because the provider followed the HMO's authorization rules and received authorization for a covered service, "the subscriber is not liable for payment of fees to the provider" (641.3154).
These protections have limits. They cover covered services while a claim is pending or in the internal dispute process; they do not erase a balance you legitimately owe once the claim is finally decided. And after an out-of-network claim is paid, the provider may still bill you the difference unless an agreement says otherwise: Florida PPO policies must carry a warning that "Nonparticipating providers may bill insureds for any difference in the amount" (627.6471(7)).
What about surprise bills?
Florida's surprise-billing law (627.64194) protects insured patients from out-of-network bills for emergency services, and for covered nonemergency services at an in-network facility when they had no chance to choose an in-network provider. ABA is usually delivered at home, school or a clinic by a provider you chose, so these rules rarely apply. The more common ABA "surprise" is a denied claim or an expired authorization, covered above. If you pay for ABA yourself, your protection is the Good Faith Estimate.
What if I was billed for sessions my child did not get?
Check each Explanation of Benefits (EOB) against your calendar. If a claim lists dates or services your child did not receive, tell the provider first; most errors are clerical. If it is not corrected, Florida law requires a fully insured plan, on your written notice, to "investigate any claim of improper billing." If the insurer reduces the provider's payment because of your notice, it must pay you 20 percent of the reduction, up to $500 (627.6131(13)). For help reading the codes, see ABA billing codes on your EOB.
Who fixes what? A step-by-step escalation
- Collect the paper. The EOB, the bill or statement, the authorization letter and your insurance card. Ask the provider for an itemized statement with dates and codes.
- Call the provider's billing office. Ask what the plan said on the claim: paid, denied (and why), pending or needing information. Many problems end here, for example a resubmitted claim or an updated coordination-of-benefits form.
- Call your plan's member services. Ask for the claim status, the reason code in plain words and what is needed to fix it. Write down the date, name and a reference number.
- Put it in writing. If the claim was denied, you can file an internal appeal. See how to appeal an ABA denial.
- Contact the regulator. For fully insured plans, the Florida Department of Financial Services Insurance Consumer Helpline, 1-877-693-5236. For self-funded employer plans, the U.S. Department of Labor's EBSA, 1-866-444-3272. For TRICARE East, Humana Military, 1-800-444-5445. See filing an insurance complaint in Florida.
While you sort it out, avoid paying a disputed balance twice, and ask the provider whether it can hold the account while the claim is reviewed. If you owe a legitimate balance, ask about a payment arrangement. One thing a provider cannot do is quietly write off your share as a routine practice; Florida law treats a general practice of waiving copays and deductibles as insurance fraud (817.234(7)(a)). See why providers can't waive copays.
How Hope Center handles billing questions
Before services start, we do a free benefits check so you know what your plan covers and what your share is likely to be. Every treatment plan is reviewed by our clinical director before it goes to insurance. If you have a question about a statement or an EOB from us, call 561-337-8865 or email office@hopecenteraba.com, and our operations or support staff will help you work out what happened and who needs to act. See insurance at Hope Center or contact us.