A lot of IOP and PHP programs in Florida end up leaving a significant chunk of revenue on the table — not because they’re providing bad care, but because their billing is messy. Wrong CPT codes, missed pre-authorization windows, credentialing gaps — payers design these processes with a lot of room for error on the provider side.
If you’re a clinician opening a program in Florida or trying to clean up an existing one, this is the operational breakdown you actually need.
Florida’s Insurance Landscape for Addiction Treatment
Florida has one of the most active behavioral health markets in the country, with a mix of Medicaid, commercial, and TRICARE coverage for substance use and mental health services.MedicaidSAMHSA
You’re usually working with three main payer categories: Florida Medicaid (and its managed care plans), commercial insurers, and TRICARE for military populations.TRICARE Each has its own coverage policies, documentation rules, and prior authorization requirements, and treating them all the same is a reliable way to tank your collections.
Florida has implemented statewide Medicaid managed care, which means most enrollees receive services through Medicaid Managed Care Organizations (MCOs) rather than fee-for-service Medicaid.Florida Medicaid You don’t just bill “Florida Medicaid” directly; you credential with each MCO separately, and each one brings its own prior authorization workflows, rate schedules, and clinical documentation standards.Florida Medicaid
CPT Codes for IOP and PHP in Florida
Getting your CPT/HCPCS codes right is non-negotiable. These are commonly used codes for substance use disorder (SUD) and related behavioral health treatment, but you should always verify coverage in each payer’s policy and fee schedule.CMS
Partial Hospitalization Program (PHP)
H0035 – Mental health partial hospitalization, less intensive (per diem)HCPCS
S9480 – Intensive outpatient psychiatric services, per diem (used by some commercial plans for PHP-like services)HCPCS
90853 – Group psychotherapy (can be used in programs that bill per-service, subject to payer rules)CPT
PHP programs typically run at around 20 or more hours of structured treatment per week, aligning with federal Medicare PHP standards that require a minimum of 20 hours per week for ongoing certification.CMS Many payers, including Medicare, reimburse PHP using per diem rates, so your documentation needs to substantiate a full day of covered services, not just individual sessions.CMS
Intensive Outpatient Program (IOP)
H0015 – Alcohol and/or drug services, intensive outpatient, per dayHCPCS
90837 – Individual psychotherapy, 60 minutesCPT
90853 – Group psychotherapyCPT
99213/99214 – Evaluation and management (E/M) codes when a physician or qualified prescriber is providing and documenting medically necessary services.CPT
IOP billing under Florida Medicaid is usually handled through the MCO benefit structure, which may use per diem or per-service methodologies depending on the plan’s contract.Florida Medicaid Commercial payers vary widely — some prefer per diem H-codes, others require strictly per-service CPT billing — so you need to know which model applies before claims go out.CMS
Case Management and Care Coordination
These codes are easy to overlook, but structured case management and treatment planning are recognized covered services in many Medicaid and commercial plans when properly authorized and documented.CMS
Florida Medicaid IOP Billing: What the MCOs Actually Require
Every Florida Medicaid MCO has its own provider manual, and they don’t always agree with each other. That said, there are themes that show up across most plans.
ASAM Criteria documentation. Florida Medicaid requires that behavioral health services be medically necessary and aligned with established clinical standards, and many plans reference the ASAM Criteria as a framework for level-of-care determinations.Florida MedicaidASAM If your clinical notes don’t clearly tie the requested level of care back to ASAM dimensions, you’re increasing your risk of denial on audit.
Active treatment plan updates. Medicaid plans and accrediting bodies expect that treatment plans are reviewed and updated regularly, often every 30 days for outpatient levels of care, to reflect medical necessity and progress.CMSJoint Commission Many MCOs bake these intervals into their utilization management criteria, and missing an update can trigger problems in concurrent review.
Service minimums. Intensive outpatient and partial hospitalization are defined as higher-intensity levels of care involving multiple hours of structured treatment per week, often described as 9 or more hours per week for IOP and 20 or more hours per week for PHP in federal and industry guidance.CMSNAATP If you consistently bill for services that don’t meet the clinical intensity for the billed level, you’re at risk for medical necessity denials or recoupments.
Telehealth. Florida Medicaid covers certain behavioral health services by telehealth when they are clinically appropriate and meet state and federal telehealth requirements.AHCA Individual MCOs may add conditions like in-person evaluations before ongoing telehealth, so you need to check each plan’s telehealth and behavioral health coverage policies rather than assuming a blanket rule.Florida Medicaid
Pre-Authorization for IOP/PHP in Florida
Pre-auth is where programs quietly lose a lot of money. A denial for lack of authorization or late authorization can mean writing off an entire admission, even if the care itself was appropriate.CMS
Who Requires It
Florida Medicaid MCOs generally require prior authorization for higher-intensity behavioral health services such as IOP and PHP, as outlined in their utilization management or behavioral health coverage policies.Florida Medicaid On the commercial side, major national plans frequently require pre-authorization for these levels of care as part of their standard medical management programs.HHS
What You Need to Submit
A complete authorization request for IOP or PHP typically includes:
A current ASAM-aligned assessment summarizing the patient’s clinical needs.ASAM
DSM-5 (ICD-10-CM) diagnosis codes, including F-codes for substance use disorders, such as F11.20 for opioid use disorder and F10.20 for alcohol use disorder.CDC
A proposed treatment plan with clear goals, frequency, and modalities of care.Joint Commission
A narrative clinical justification explaining why this level of care is medically necessary and the anticipated length of stay.CMS
Payers routinely delay or deny requests when documentation is incomplete or inconsistent with their criteria, which is why building an internal checklist is so important.HHS
Authorization Timelines
Health plans commonly set timeframes such as 24–72 hours for urgent/expedited requests and several business days for standard or routine prior authorization decisions.HHS Your internal workflow should aim to submit prior auth on or before day one of admission so you’re not providing days of uncovered care while paperwork is still pending.
Concurrent Reviews
An initial authorization approval rarely covers the entire course of treatment. Most payers schedule concurrent (continued-stay) reviews on a recurring cycle, often every 7–14 days for higher-intensity levels of care, to verify ongoing medical necessity.CMS Missing a concurrent review deadline or submitting thin documentation can result in retroactive denial for days that were already rendered.
Common Denial Codes and How to Respond
Denials aren’t always final, but they are time-consuming. Florida-regulated plans must follow specific timelines for grievances and appeals, including notice and response deadlines.Florida OIR
Some denial codes you’ll see over and over:
CO-4 (Inconsistent modifier or procedure code). This usually indicates a mismatch between the CPT/HCPCS code, modifier, or place of service. The fix is often technical: verify code combinations against current coding guidance and payer-specific billing manuals before resubmitting.CMS
CO-50 (Not medically necessary). This is a clinical denial, not a typo issue. You’ll need to request a peer-to-peer review or submit a clinical appeal that leans heavily on ASAM criteria, documented risk, functional impairment, and response to treatment.ASAMCMS
CO-96 (Non-covered charge). This indicates the service is not covered under the patient’s specific benefit plan. The best defense is solid front-end eligibility and benefits verification for SUD IOP/PHP coverage, including documentation of the call or portal verification.CMS
PR-204 (Service not covered by this payer). This usually points to eligibility or coordination-of-benefits issues — for example, the patient’s primary coverage changed or terminated. Eligibility should be checked at admission and re-verified regularly for Medicaid and exchange plans, which can change month to month.Medicaid
Credentialing for Florida Payers
You can’t bill until you’re contracted and credentialed, and that process often takes several months. National surveys suggest payer credentialing and contracting can routinely run 60–120 days, sometimes longer, depending on completeness of the application and payer backlog.HHS
For Florida Medicaid MCOs, you have to credential with each plan individually — there’s no single, unified application that gets you into all networks.Florida Medicaid Each application typically requires your NPI, facility license, clinical staff roster, proof of professional and general liability insurance, and sometimes accreditation documentation.CMS
For commercial payers, CAQH ProView is the standard central repository for provider demographic and credentialing information, and payers often pull directly from that profile.CAQH Outdated information in CAQH is a common cause of delays, so keeping it current is worth the time.
Florida-Specific Compliance Considerations
Florida has some of the tightest behavioral health rules in the country, largely in response to patient brokering scandals and fraud cases in the 2010s.Florida OPPAGA
Marchman Act. The Marchman Act (Chapter 397, Florida Statutes) governs voluntary and involuntary assessment and treatment of substance abuse in Florida.Florida Statutes If your program works with patients under court or family-initiated Marchman proceedings, you need to understand how the legal status of the admission affects consent, documentation, and coordination with payers.
Anti–patient brokering law (F.S. 817.505). Florida’s patient brokering statute makes it unlawful to offer or pay any commission, bonus, rebate, kickback, or bribe to induce the referral of a patient to or from a health care provider or facility.Florida Statutes This applies directly to referral relationships, sober home arrangements, and marketing or outreach compensation structures, and violations can result in criminal penalties and loss of licensure.Florida Statutes
Baker Act documentation. The Baker Act (Chapter 394, Florida Statutes) addresses involuntary examination and placement for mental illness.Florida Statutes When patients transition from an acute Baker Act setting into your program, the documentation around discharge, admission, and initial assessment can affect both medical necessity reviews and how the episode is billed.
FAQ
What CPT codes are used for IOP billing in Florida?
The primary HCPCS code many payers use for intensive outpatient substance use services is H0015 (alcohol and/or drug services, intensive outpatient, per day), with some plans also covering 90837 and 90853 on a per-service basis when billed according to their policies.HCPCSCPT Always confirm whether a payer wants per diem or per-service billing before you submit claims.
Does Florida Medicaid cover IOP for substance abuse?
Yes, Florida Medicaid covers substance use disorder treatment, including intensive outpatient and partial hospitalization services, when medically necessary and delivered by enrolled providers under its managed care program.Florida MedicaidSAMHSA Coverage details and authorization requirements are set by each Medicaid MCO, so you need to review each plan’s behavioral health policy.
How long does prior authorization take for IOP/PHP in Florida?
Many health plans process urgent or expedited prior authorization requests within about 24–72 hours, with routine decisions taking several business days depending on the plan.HHS Submitting your authorization request on or before day one of admission reduces the chance you’ll end up providing uncovered days of care.
What is the ASAM Criteria and why does it matter for billing?
The ASAM Criteria is a widely used set of guidelines for assessing addiction severity and matching patients to the appropriate level of care, including outpatient, IOP, and residential services.ASAM Florida Medicaid and many commercial payers expect ASAM-informed documentation to support level-of-care decisions, and weak alignment makes claims more vulnerable to denial in audits.Florida Medicaid
Can Florida IOP programs bill telehealth services through Medicaid?
Florida Medicaid covers certain behavioral health services via telehealth when they meet the state’s telehealth coverage rules and medical necessity criteria.AHCA Individual Medicaid MCOs can add additional conditions, so you should review each plan’s telehealth policy and document that you’ve met any in-person or technology requirements.
What’s the appeals process for a denied IOP claim in Florida?
Florida-regulated health plans must follow state rules on grievance and appeals timelines, including prompt acknowledgement of appeals and resolution within specified timeframes.Florida OIR For clinical denials, it’s usually worth requesting a peer-to-peer review and submitting a written appeal that clearly ties your documentation to ASAM criteria and the plan’s medical necessity policy.ASAM
Work With People Who’ve Done This Before
Billing for addiction treatment in Florida is a full-time job — and it is separate from actually running a clinical program. Most new IOP/PHP operators either undercollect because they can’t navigate payer requirements, or they get audited because their documentation doesn’t match their billing.
ForwardCare is a behavioral health MSO (Management Services Organization) that partners with clinicians, sober living operators, healthcare entrepreneurs, and investors to launch and scale behavioral health treatment centers. We handle the business side — licensing support, insurance credentialing, billing, compliance, and operational infrastructure — so our partners can focus on growth and clinical quality.
If you’re serious about opening or expanding a behavioral health treatment center but don’t want to navigate the business side alone, ForwardCare may be worth a conversation.