Behavior Analysis Services Information

All rendering, ordering, prescribing, or attending providers enrolled in Florida Medicaid must have a National Provider Identifier (NPI) on file with the Agency to comply with federal requirements. This includes all Medicaid-enrolled behavior analysis providers, provider type 39, and type 39 specialties – lead analysts (specialty type 392), assistant behavior analysts (specialty type 391), registered behavior technicians (specialty type 390), and behavior analysis groups (specialty type 393).
If an enrollment file does not include an NPI, behavior analysis providers must provide an NPI to the Medicaid fiscal agent as soon as possible.

Please see this March 4, 2022 provider alert for detailed information regarding:

• How to confirm whether you have an NPI in your file,
• How to obtain an NPI if you do not already have one, and
• How to update your enrollment file with your NPI

Claims submitted without necessary rendering, billing, and referring providers’ NPIs will deny starting July 1, 2022.
This is a federal requirement. Extensions or exemptions cannot be granted.

Fee Schedule Transition to Current Procedural Terminology (CPT) Codes

The Agency is converting the Behavior Analysis fee schedule from its current Healthcare Common Procedure Coding System (HCPCS) Level III code structure to the American Medical Association (AMA) Behavior Analysis Current Procedural Terminology (CPT) code structure.

• July 29, 2022 BA Fee Schedule Training
• FAQs about the CPT code transition and coverage policy updates can be found here.
• The CPT-based behavior analysis fee schedule will be effective August 1, 2022.
• The updated 2022 fee schedules are available on the Agency’s reimbursement schedule page, Rule 59G-4.002, Provider Reimbursement Schedules and Billing Codes.
• The 2022 BA fee schedule can be downloaded here.
• The Agency will host a webinar to introduce Florida Medicaid coverage guidelines. That training will be announced via a provider alert.

The Agency is working with eQHealth Solutions to ensure a smooth prior authorization and billing conversion to the new codes.

• Providers should continue submitting assessment, reassessment, and 180-day treatment prior authorization requests that begin prior to August 1, 2022, to eQHealth Solutions using the current HCPCS Level III codes on the current fee schedule.
• Beginning June 29, 2022, providers will be able to:
  • Convert authorized assessments, reassessments, and behavior plans that begin prior to August 1, 2022, to the new codes.
  • Submit NEW prior authorization requests using the August 1, 2022, CPT codes for assessment, reassessment services to be delivered on or after August 1, 2022, and 180-day treatment periods that begin on or after August 1, 2022.
• Beginning August 1, 2022:
  • All authorization requests must reflect CPT codes.
  • All claims for dates of service on August 1, 2022, and thereafter must use CPT codes.
• Visit the eQHealth website for detailed instructions
• eQHealth will post additional information and updates as available to the eQHealth website http://fl.eqhs.com.

If you have questions regarding the behavior analysis prior authorization process, contact eQHealth Solutions via email at pr@eqhs.com or call 855-440-3747.

The Agency is preparing a BA Services Coverage Policy update to coincide with the adoption of the CPT-based fee schedule.

• The current draft policy (updated July 20, 2022) is posted on the Agency’s Rules in Process website. 
• Future public meetings and workshops will be scheduled and noticed to providers through provider alerts.

The Agency for Health Care Administration (Agency) has extended the temporary moratorium on enrollment of new BA group providers and individual providers practicing independent of a group in Miami-Dade and Broward counties for an additional six months through November 13, 2022.

During this extension, the Agency will make operational and systematic updates to allow enrollment to begin at the expiration of this moratorium.

The goal of the extended, temporary moratorium is to fight fraud and safeguard taxpayer dollars, while ensuring patient access to care. Authority to impose a moratorium was included in the Affordable Care Act, and the Agency, with the approval of the Centers for Medicare and Medicaid Services, is exercising that authority.

What is New:

1. Are currently enrolled in the Florida Medicaid program at an existing service location; and,
2. Have no outstanding overpayments owed to the Agency (as indicated by a Final Order for which full payment has not been made); and,
3. Have experience delivering Florida Medicaid behavior analysis services or pediatric therapy services (physical, occupational, or speech and language) for the last five years.

Providers that meet the three requirements above must do the following:

(1) The purchasing BA group provider and the existing BA group must notice the Agency and complete the formal Florida Medicaid CHOW process. Information on the CHOW process is on the Agency’s new CHOW resource page, found here.

• The application for CHOW will be denied if there are any material defects or any material deviations from the information previously furnished to the Agency through the notice process.
• A Medicaid provider application denial is not challengeable by a provider applicant.

(2) The purchasing provider must provide proof of an enforceable bond in an amount equal to that which the selling provider has been reimbursed by the Medicaid program since the selling provider’s initial enrollment date. The purpose of the bond is to cover any overpayments the Agency may identify through an audit of the selling provider.

• The bond must remain in effect for 12 months from the date of the purchasing provider’s notice to the Agency seeking authorization to apply.
• The purchasing provider must direct the release of funds from the bond should the Agency determine that there was an overpayment during the tenure of the selling provider.
• The only exception to the requirement to direct the release of funds is if the overpayment amount is satisfied by the selling provider or the purchasing provider before the Agency demands payment under the bond.
• The overpayment determination would be considered enforceable, for purposes of the bond release only, at the time of issuance of a final audit report offering administrative hearing rights.
• The provision of s. 409.913(16), Florida Statutes is not waived. This provision includes the requirement that if a provider voluntarily relinquishes its Medicaid provider number after receiving written notice that the Agency is conducting an audit or investigation, that the Agency shall impose the sanction of termination for cause against the provider. As such, if the selling provider has received said notice, the voluntary termination will be regarded as a termination for cause and all relevant notices (including notice to CMS) will follow.

For questions related to this alert, or for assistance with provider enrollment, please call the Florida Medicaid Provider Enrollment Contact Center at 1-800-289-7799, Option 4.

MDT Updates: Provides information to behavior analysis providers in Regions 4 and 7

The Agency directed eQHealth Solutions, Inc. to implement a multidisciplinary team approach to reviewing prior authorization requests for behavior analysis services in Regions 4 and 7, as a pilot, beginning July 1, 2019. As a part of the MDT review process, all requests for more than 20 hours per week must undergo a telephone or face-to-face staffing to ensure the child is receiving all necessary services and supports. While this approach has proven valuable in obtaining additional information about the needs of the child, the Agency has identified opportunities to streamline and expedite the process, while continuing to engage providers and parents.

• If the request for BA services can be approved after completion of the desk review, the provider will be notified electronically via eQSuites, and the care coordinator will contact the parent/legal guardian to notify of the final decision.
• If the request for BA services cannot be approved because information is missing, there are inconsistencies in the record, or the request does not meet medical necessity (in whole or part), eQHealth will schedule a peer- to-peer telephonic review with the provider in lieu of an MDT meeting. If the concerns can be resolved during the peer-to-peer review, the case will be approved.
  • If the request still cannot be approved after the peer-to-peer review, eQHealth will call the parent to discuss the decision and follow with the standard denial letter with appeal rights.
• If eQHealth believes the child may benefit from additional services or supports, a care coordinator will contact the parent to discuss how to initiate those services. BA services will not be delayed while this is occurring.

eQHealth will only initiate MDT meetings in cases where convening treatment providers may be of benefit in maximizing the treatment outcomes, particularly where progress has stalled or regressed over several review periods.

It is of chief importance to us to solicit input from parents prior to making a service authorization decision, so eQHealth will continue to contact the child’s parent/guardian prior to completing the review to collect information and to discuss any additional needs that may have arisen.

Florida Medicaid suspended Electronic Visit Verification for Behavior Analysis Services effective February 5, 2022. This announcement comes following the Agency’s November 10, 2021 provider alert which announced that the Agency will transition to the American Medical Association (AMA) Behavior Analysis Current Procedural Terminology (CPT) code structure on July 1, 2022.
Behavior analysis (BA) providers were no longer able to utilize the Netsmart EVV system to verify Medicaid BA services beginning February 5, 2022 and were required to begin billing directly using the Florida Medicaid Secure Web Portal.  Providers have the option of direct data entry, sending in an 837P claims transaction, or using a Billing Agent or Clearinghouse.

Training and Contact Information

Training on the use of the secure Web Portal is located on the Florida Medicaid Public Web Portal at: https://portal.flmmis.com/FLPublic/Provider_ProviderServices/
Provider_Training/Provider_Training_Presentations/tabId/84/Default.aspx

You may also contact the Provider Services main telephone line at 1-800-289-7799 and select Option 7: Provider Services Contact Center and Field Services Representatives.

Additional Information

A link to a list of questions and answers can be found on the Agency’s website under Helpful Information and Presentations below.

If providers would like to retain their historical EVV data, step by step instructions are provided in a new Netsmart Data Export User Guide. The User Guide contains screenshots of step by step instructions for the following items:

• Exporting Visit Detail Report
• Exporting Time Log
• Exporting Recipients List
• Exporting Visit History
• Exporting Historical Claims
• Exporting In-Process Claims

Please click here to review the Netsmart Data Export User Guide

Additionally, an accompanying training video has been made available to Providers and can be accessed via the following link: https://4tellus.com/ahca-ba-training-resources/#tutorials

All materials listed above are also stored on the Netsmart AHCA BA EVV website at the following link: https://4tellus.com//ahca-ba-training-resources/.