Applied behavior analysis (ABA)

• You need PA for adaptive behavior treatment: common procedural terminology (CPT) codes 97153-97158.

• You don’t need PA for adaptive behavior assessments: CPT codes 97151 and 97152. 

We may deny payment when you provide services without PA.   

What is the standard time frame for PA approval?

We authorize services for 6 months at a time.  

Do you need a specific ABA PA form? Will you need clinical documentation for the review? 

Yes, you need the ABA PA form (PDF) for initial and reauthorization of services. And yes, you’ll need clinical documentation as listed on the PDF.

Do providers delivering ABA services need to use the new CPT adaptive behavior and treatment codes 97151-97158, 0362T and 0373T?  

Yes. You need to use the CPT codes 97151-97158, 0362T and 0373T when providing adaptive behavior assessment and treatment. We require the use of CPT codes.

Is the PA for ABA only applicable when Mercy Care is the primary payer or is it for secondary as well?  

If members have other primary insurance, you may not need PA. You do need PA if:

• Mercy Care is the primary payer for services

• The primary insurance doesn’t cover the service

• The member has exhausted their benefit

Note which situation applies on the PA request form. 

When serving a family who has private insurance, how are copays and deductibles paid? 

AHCCCS will pay deductibles and copays to providers who are registered with them and providing AHCCCS-covered services. This doesn’t require a contract with AHCCCS. But by registering, you agree not to balance bill members.

If the contract between you and Mercy Care doesn’t state otherwise, Mercy Care pays the lesser of these two differences: 

• The primary insurance paid amount and the primary insurance rate (i.e., the member’s copayment required under the primary insurance)

• The primary insurance paid amount and your contracted rate 

How do I submit claims and get reimbursed for ABA services provided to members? 

Check our claims page to learn how to submit claims online or by mail.

How does Mercy Care coordinate care between plans to ensure children are getting medically necessary ABA services? 

To avoid barriers to member care and delays in your reimbursements, AHCCCS has instructed us to:

• Reimburse AHCCCS-approved children’s services (18 years and younger) at a primary level

• Pursue coordination of benefits via a post-adjudication reclamation process

ABA services are part of this process. We encourage you to submit an Explanation of Benefits (EOB) from the primary plan with each claim, but we won’t deny services based on coordination of benefits. 

I know the services I’m providing are non-covered by the member’s primary insurance. But the services appear to be covered by Medicaid. Do I have to bill the primary insurance each time for a denial before billing Medicaid?

It depends on the services you’re providing. We’re aware that many behavioral health services are considered non-covered by Medicare and primary insurance plans. Services that begin with alpha characters H, S and T are part of our internal bypass system. We consider these services as primary and don’t expect you to bill the primary insurance for a denial. 

Examples include but aren’t limited to: S5150 (respite) and T1016 (case management).

If members have primary coverage, we override editing related to coordination of benefits and pay the services as primary when no primary explanation of benefits is attached to the claim. 

If the services are considered covered by members’ primary plan, we expect you to bill the primary first so that the Medicaid plan can cost share.

For remaining services that don’t begin with an H, S, or T, we expect you to bill the primary payer first. 

Should board-certified behavior analysts (BCBAs) bill each assessment encounter or submit an aggregate of all assessment encounters with direct and non-direct work? 

Follow your normal billing practices, as we can administer either.