Getting a letter that says your child's ABA therapy has been denied, reduced or stopped is frightening. It is also, very often, reversible.
The most important thing to understand: a denial starts a clock. Some of the deadlines are short, and one of them — the one that keeps your child's current services running while you fight — is only ten days.
First, identify what you received
If your child has Medicaid through a managed care plan, the denial letter is usually called a Notice of Adverse Benefit Determination. It must tell you what was denied, why, and what your appeal rights are. Keep the envelope. The date on the notice is what the deadlines run from.
If your child has commercial insurance, the letter is typically an Explanation of Benefits or an adverse determination, and the appeal path is set by the plan and by Florida insurance law rather than by Medicaid rules.
The three deadlines that matter (Medicaid managed care)
10 days — to keep services going
If your child is already receiving ABA and the plan is reducing, suspending or terminating it, you can ask for services to continue during the appeal. To get that, you generally must file the appeal and specifically request continuation within 10 days of the date on the notice, or on or before the first day services are set to change — whichever comes first.
This is the deadline families miss most often, because it is short and because it is easy to assume that appealing is enough. Appealing is not enough. You have to ask for continuation, in writing, and say so plainly.
60 days — to file the plan's internal appeal
You have 60 days from the notice to file an appeal with the health plan itself. You must complete the plan's internal appeal before you can request a state fair hearing. Asking for a hearing first can get your request rejected.
120 days — to request a Medicaid Fair Hearing
Once the plan issues its Notice of Plan Appeal Resolution, you have up to 120 days from that notice to request a fair hearing with the state.
Requests go to the Agency for Health Care Administration, Medicaid Hearing Unit — P.O. Box 7237, Tallahassee, FL 32314-7237, telephone 1-877-254-1055 (toll-free), or MedicaidHearingUnit@ahca.myflorida.com.
Read the dates on your own letter and follow those. They are what govern your case. The figures above are the general rules; your notice is the authority.
What to put in the appeal
Denials of ABA are frequently overturned on documentation rather than on argument. Strong appeals usually include:
- The comprehensive diagnostic evaluation and the physician's order or prescription for behavior analysis services.
- The behavior assessment and behavior plan, signed by the Lead Analyst and by you, with measurable goals.
- Data showing progress — or showing regression if services stop. Numbers are more persuasive than adjectives.
- A letter of medical necessity that answers the specific reason given in the denial. If the plan said "insufficient documentation of medical necessity," send the documentation it says is missing.
- For a child under 21, a reference to EPSDT, under which services can exceed normal coverage limits when medically necessary to correct or ameliorate a condition.
What we do on our side
If your child is our client, you do not chase this alone. Our billing and clinical teams assemble the record, write the medical necessity letter with the Lead Analyst, meet the deadlines, and keep you updated. Call (786) 652-6945 or email billing@americaninstituteofmentalhealth.com the day the letter arrives — not the week after.
Free help that is not us
You are entitled to independent help, and using it is a good idea:
- Florida Health Justice Project — free plain-language guides and toolkits on Medicaid appeals.
- Disability Rights Florida — the state's federally designated protection and advocacy organization.
- Your plan's member services line — the number is on your child's card, and they must tell you how to appeal.
One thing worth saying plainly
A denial is not a judgment about your child, and it is not usually a final answer. Many are administrative: a missing signature, an expired evaluation, a code that did not match. Send what is missing, meet the dates, and ask for help early.
Sources: Florida Agency for Health Care Administration, Medicaid Fair Hearing (Statewide Medicaid Managed Care). Sunshine Health, Complaints, Grievances and Appeals. Federal Medicaid managed care appeal rules, 42 C.F.R. §§ 438.402, 438.408 and 438.420. Florida Medicaid Behavior Analysis Services Coverage Policy (AHCA, December 2024). This article is general information, not legal advice; deadlines and requirements printed on your own notice control your case.