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Read the denial. Prepare your appeal.
Start with the reason and deadline on the denial letter. Use this kit to identify the plan, organize records and prepare your questions. An appeal does not guarantee coverage.
Plan scope, Florida mandate, federal appeal timing and EPSDT checked September 12, 2026. Individual benefits, current adjusted caps and continued-coverage rights need plan-specific confirmation. Next source review planned October 12, 2026.
Read the reason and deadline
Keep the denial letter and note when you received it. Find the denied service, reason, appeal instructions and filing deadline. Ask for a copy if any part is missing.
- For a medical-necessity denial, ask for the clinical criteria used. Discuss the stated reason with the treating clinician.
- For a benefit exclusion, network issue or missing authorization, ask the plan to identify the exact benefit provision and any correction process.
- Ask which appeal and external-review rights apply to this plan. Medicare, Medicaid, government plans and grandfathered plans may use different procedures.
Find out which plan you have
Ask the plan administrator: “Is this plan fully insured or self-funded? Which regulator handles coverage complaints?” Request the current benefit document or Summary Plan Description. Ask which state issued an insured policy. An insurer name on the card is not enough to establish these details.
Private-employer and government plans have different routes
Private-employer self-funded plans generally fall under federal ERISA rules and are outside Florida's autism insurance mandate. A government employer's self-funded plan follows a different regulatory route. Ask the plan administrator to identify the plan type and responsible regulator.
VerifiedSource: Florida Department of Financial Services, autism coverage · How we verify
For a private-employer ERISA plan, the Department of Labor's Employee Benefits Security Administration (EBSA) can help with benefit questions. Florida's Department of Financial Services can help identify whether a policy falls within its authority. Ask about the correct route for government, military, Medicare or Medicaid coverage.
Florida coverage rules
Check plan type and eligibility together
Florida's autism mandate covers specified state-regulated large-group plans and the state employee program. It requires screening and prescribed speech, occupational, physical and ABA therapies, subject to the law's conditions. The person must be under 18, or 18 or older in high school, and diagnosed with a developmental disability at age 8 or younger. Individual and small-employer plans are excluded from this mandate; other coverage rules may apply.
VerifiedSource: Florida Statutes, section 627.6686 · How we verify
Statutory figures are not a current benefit quote
Section 627.6686 lists base limits of $36,000 annually and $200,000 over a lifetime, with annual medical-inflation adjustments to the maximum benefit. The statute also preserves other available coverage. Federal benefit and parity rules can affect whether a limit may be applied.
VerifiedSource: Florida Statutes, section 627.6686 · How we verify
Current adjusted limits need confirmation
We have not verified the current adjusted dollar figures or whether any limit applies to your plan. Ask for its written benefit terms and the legal basis for a proposed cap before relying on a dollar amount.
Not yet verified as of . Treat this as unconfirmed. What this meansCheck federal mental health parity
Parity depends on the plan and benefit
MHPAEA generally restricts differences between mental-health or substance-use benefits and medical or surgical benefits in plans it covers. It addresses financial requirements and treatment limits, including how prior authorization is applied. Exceptions include certain small self-funded plans. Parity does not by itself establish that a particular ABA request must be approved.
VerifiedSource: CMS, Mental Health Parity and Addiction Equity · How we verify
Ask for the plan's medical-necessity criteria and an explanation of any different limits. Keep its written response. Raise a suspected parity issue with the regulator responsible for the plan. This guide does not decide whether a specific restriction violates the law.
The call log
Print this table or copy it into your own notebook. Keep completed records on your device or paper. Do not send medical or child details to SpectrumBeacon.
| Date | Representative | Reference number | Answer | Documents sent | Follow up by |
|---|---|---|---|---|---|
Appeal letter template
Use the plan's required form if it has one. Fill in this outline privately. Ask the treating provider which records support the request, then send the packet through the plan's accepted channel. Keep proof of receipt.
Subject: Appeal of denial [claim or reference number]
To the Appeals Department of [plan]:
I am appealing the denial dated [date] for [service]. The stated reason is [copy the reason].
I request reconsideration because [respond to the reason and cite the attached benefit or clinical evidence].
[If urgent: My treating clinician explains the risk of waiting in the attached statement. Please consider an expedited appeal.]
[If an approved course of care is being reduced: Please explain any right to continued coverage and its filing deadline. I request continuation while the appeal is reviewed if those rules apply.]
Enclosed: [list documents]. Please confirm receipt, the decision deadline and whether anything else is required.
[Adult contact information and the identifiers the plan requires]
Appeal timing
For plans subject to ACA internal-appeal rules, CMS lists 30 days for a non-urgent service not yet received and 60 days for a service already received. Ask the plan to confirm which rules apply and calendar your own filing deadline from the denial notice.
Urgent-care appeal timing
For plans subject to the ACA internal-appeal rules, CMS gives a 72-hour decision deadline after receipt of an urgent-care appeal. Urgency depends on the risk from waiting, not simply on an earlier approval ending. Ask the treating clinician to explain the risk and confirm the applicable process with the plan.
VerifiedSource: CMS, Appealing Health Plan Decisions · How we verify
HealthCare.gov explains urgency: a standard wait must pose serious risk to life or function. A qualifying expedited external review must be decided as soon as the condition requires, no later than 72 hours after receipt. Do not assume that every expiring authorization qualifies.
Continued coverage is a separate question. Its conditions and filing deadlines are not established for your plan here. Ask promptly, especially before an approved course of care is reduced or stopped.
Read the final denial notice for external-review eligibility, destination and deadline. Use its instructions and ask the responsible regulator for help if the notice is unclear.
If coverage is Medicaid
EPSDT for eligible members under 21
For eligible Medicaid members under 21, EPSDT requires medically necessary care within the federal Medicaid benefit categories in section 1905(a) to correct or improve identified conditions, even when the state does not cover that service for adults. Medical necessity is decided case by case. This does not guarantee approval of every requested therapy or number of hours.
VerifiedSource: Medicaid.gov, EPSDT · How we verify
Medicaid uses its own appeal and fair-hearing rules. Follow the denial notice and ask the Medicaid plan or agency about the deadline and any continued-benefit request. Read the federal overview.
Common questions
Does the Florida autism mandate apply to my plan?
Florida's autism mandate covers specified state-regulated large-group plans and the state employee program. It requires screening and prescribed speech, occupational, physical and ABA therapies, subject to the law's conditions. The person must be under 18, or 18 or older in high school, and diagnosed with a developmental disability at age 8 or younger. Individual and small-employer plans are excluded from this mandate; other coverage rules may apply.
Florida Statutes, section 627.6686. Checked .
My employer's plan is self-funded. Is ABA just not covered?
The plan type alone does not answer that. Read the benefit document and ask whether ABA is covered, which authorization rules apply, and whether federal parity protections apply to this plan.
Florida Department of Financial Services, autism coverage. Checked .
How fast must the plan decide an urgent appeal?
For plans subject to the ACA internal-appeal rules, CMS gives a 72-hour decision deadline after receipt of an urgent-care appeal. Urgency depends on the risk from waiting, not simply on an earlier approval ending. Ask the treating clinician to explain the risk and confirm the applicable process with the plan.
CMS, Appealing Health Plan Decisions. Checked .
Can Medicaid deny ABA for my child?
For eligible Medicaid members under 21, EPSDT requires medically necessary care within the federal Medicaid benefit categories in section 1905(a) to correct or improve identified conditions, even when the state does not cover that service for adults. Medical necessity is decided case by case. This does not guarantee approval of every requested therapy or number of hours.
Medicaid.gov, EPSDT. Checked .