Sunshine Health (FL Medicaid)

MedicaidFL

ABA billing requirements · Source: Sunshine Health — Florida SMMC Prior Authorization (Optum/ProviderExpress)

High confidence

Verified 2026-03-01

Authorization Requirements

Requires prior auth Yes

Initial auth duration6 months

Renewal auth duration6 months

Submission deadline14 days

Unit tracking cadenceTotal

Requires FBA Yes

Diagnostic eval validity36 months

Re-eval cadenceEvery 6 months

BH carve-out managerOptum

State licensure requiredBCBA state certification required via FL Agency for Health Care Administration

Documentation Requirements

Parent signatures required Yes

Start/stop times required Yes

Treatment plan componentsASD diagnosis, Functional Behavior Assessment, Baseline data, Measurable goals, Intervention strategies, Parent training plan, Discharge criteria

Progress summary cadenceEvery 6 months

Policy Notes

Sunshine Health (Centene) is a major Florida Statewide Medicaid Managed Care (SMMC) plan. ABA prior auth required — submitted through ProviderExpress (Optum behavioral health carve-out). BCBA must be enrolled with both Sunshine Health and Optum FL.

CPT & Modifier Rules

CPT rules require a free account

View H-codes, modifiers, unit limits, and billing restrictions for Sunshine Health (FL Medicaid).

Official policy source:Sunshine Health — Florida SMMC Prior Authorization (Optum/ProviderExpress)

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Data last verified: 2026-03-01 · Confidence: High · See our methodology

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