A diagnostic evaluation is required to establish medical necessity for ABA services. For Florida Medicaid and most insurance plans, coverage is typically based on a qualifying diagnosis such as Autism Spectrum Disorder (ASD) and supported by clinical evaluation and documentation of functional impairment.

Common diagnoses that may support ABA services include:

• Autism Spectrum Disorder (ASD – F84.0 and related codes)

• Attention-Deficit/Hyperactivity Disorder (ADHD – F90.2) (varies by insurance plan)

• Conduct Disorder

• Oppositional Defiant Disorder (ODD)

• Other developmental or behavioral conditions as determined through clinical evaluation

Diagnostic evaluations are completed by qualified licensed professionals, such as physicians and/or psychologists, depending on the type of assessment required by the insurance plan.

The Comprehensive Diagnostic Evaluation (CDE) is a required document for Florida Medicaid and many insurance plans to establish medical necessity for ABA services.

The CDE is a formal clinical evaluation completed by a qualified licensed provider and typically includes the use of standardized tools and assessments such as:

• Developmental and adaptive behavior assessments (e.g., Vineland Adaptive Behavior Scales)

• Autism-specific assessments when applicable (e.g., ADOS-2, CARS-2)

• Cognitive and/or developmental testing as appropriate

• Behavioral and functional assessments across environments

• Clinical interview, observation, and review of medical/developmental history

The CDE includes:

• A confirmed diagnosis when applicable

• Documentation of developmental and behavioral needs

• Impact on daily functioning across settings

• Clinical recommendation for treatment, including ABA services when appropriate

For Florida Medicaid, the CDE is used to support authorization by demonstrating medical necessity and outlining the individual’s need for ABA services. This document is required prior to approval and initiation of treatment.

A referral is required to begin the ABA authorization process for Florida Medicaid and most insurance plans. It is the first step in connecting families to a Comprehensive Diagnostic Evaluation (CDE) and initiating the prior authorization process for ABA services.

For Florida Medicaid and managed care plans, the referral must support medical necessity and be completed prior to submission for insurance approval.

The referral must include the following:

• Child’s full name and date of birth

• Diagnosis and diagnostic DSM 5 or ICD-10 code(s)

• Clear recommendation for ABA therapy (must be written on the referral)

• Signature from a licensed physician (MD or DO only)

• Referral date (must be less than one year old at the time of submission)

The referral is submitted along with supporting documentation, including the CDE and insurance information, to begin authorization for ABA services.

For ABA services delivered in a school setting, Florida Medicaid requires submission of the student’s Individualized Education Plan (IEP) with the authorization request.

If an IEP is not available or does not include ABA services, the provider must include documentation that justifies the requested services and includes an estimated timeframe for when an IEP will be completed or updated.

If the school does not provide an IEP, a 504 Plan may be submitted in its place.

If neither an IEP nor a 504 Plan is available, documentation must include:

• The name of the school

• A written explanation confirming that neither an IEP nor 504 Plan is available

This documentation is required to support medical necessity and ensure compliance with Florida Medicaid authorization requirements for services provided in the school setting.

Prior treatment records help support continuity of care and provide important clinical history for ABA authorization and treatment planning.

These records may include documentation from previous or current services such as:

• ABA therapy reports

• Speech therapy (ST) records

• Occupational therapy (OT) records

• Behavioral health or counseling notes

• Progress summaries or treatment plans

This information helps our clinical team and insurance providers understand previous interventions, response to treatment, and ongoing areas of need to support medical necessity for ABA services.