Applied Behavior Analysis
Applied Behavior Analysis, also known as ABA, is one type of service that is used to improve or change behavior to help the member in a meaningful way. Treatment is based on the needs of the individual and family. The clinical team will develop a service plan that may include ABA and/or other services to help support and teach new skills to support caregivers in assisting the member to improve their own helpful behaviors, in addition to reducing behaviors that could affect learning or be harmful to the member.
ABA is a covered service for Mercy Care members. Members must receive ABA services from a provider in Mercy Care’s provider network. Medically necessary services, including ABA, are determined by the member’s Child and Family Team (CFT) or Adult Recovery Team (ART).
Frequently Asked Questions
1. Which codes require a Prior Auth for ABA?
Effective November 1, 2019, a prior authorization is required for Adaptive Behavior Treatment (CPT Codes 97153-97158). Adaptive Behavior Assessments (CPT Codes 97151 and 97152) will not require authorization. Service(s) rendered without authorization may be denied for payment.
2. What is the standard timeframe of Prior Auth approval?
Mercy Care will authorize services for 6 months at a time.
3. Will Mercy Care require a specific ABA prior auth form to be used, and will clinical documentation be requested during review?
Yes, Mercy Care developed an ABA PA form that is required for initial and re-authorization of services. Visit our website to access the form and list of clinical documentation required for authorization.
4. Does Mercy Care require providers delivering ABA services to use the new CPT Adaptive Behavior and Treatment codes 97151-97158, 0362T and 0373T?
Yes. Starting October 1, 2020, Mercy Care expects providers to utilize the CPT Codes 97151-97158, 0362T and 0373T when providing Adaptive Behavior Assessment and Treatment. For more descriptions on the codes, please use the following resources:
Third Party Liability (TPL):
1. Is the prior authorization for ABA only applicable when Mercy Care is primary or is it for secondary as well?
Yes, prior authorization is required when Mercy Care is the primary funder for services. If the member has other primary insurance there is no authorization required. However, if the primary insurance does not cover the service or the member has exhausted their benefit, authorization will be required. Please note this on the authorization request form.
2. When serving a family who has private insurance, how are co-pays and deductibles paid?
AHCCCS will pay deductibles and copays to providers who are registered with AHCCCS and providing AHCCCS-covered services; this does not require a contract with AHCCCS. However, by registering, the provider agrees to not balance bill the insured (the member). If the contract between Mercy Care and the provider does not state otherwise, Mercy Care shall pay the lesser of the difference between:
- The Primary Insurance Paid Amount and the Primary Insurance rate, i.e. the member’s copayment required under the Primary Insurance, OR
- The Primary Insurance Paid amount and the Contractor’s Contracted Rate
3. How does a provider submit claims and get reimbursed for the ABA service delivery provided to the member?
Please visit https://www.mercycareaz.org/providers/claims for information on submitting claims electronically or via mail.
4. How do I coordinate care between plans to ensure children are getting medically necessary ABA services?
To avoid barriers to member care and delays in provider reimbursements, AHCCCS has instructed Mercy Care to reimburse AHCCCS-approved children’s services (18 years and younger) at a primary level and pursue coordination of benefits via a post-adjudication reclamation process. ABA services are part of this process. Mercy Care encourages providers to submit an EOB from the primary plan with each claim; however, services will not be denied based on coordination of benefits.
5. As a provider, I know the services I am providing are non-covered by the members primary insurance; however, the services appear to be covered by Medicaid. Do I have to bill the primary insurance each time for a denial prior to billing Medicaid?
The answer to this question depends on the services being provided. Mercy Care is 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, where we will consider the services as primary and do not expect the provider to bill the primary insurance for a denial.
Examples include but are not limited to: S5150 (Respite), and T1016 (case management). If the member has primary coverage, Mercy Care will 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 the member’s primary plan, the provider is expected to bill the primary first so that the Medicaid plan can cost share. For remaining services being provided that do not begin with an H, S, or T, the provider is expected to bill the primary payer first.
6. Does Mercy Care want BCBAs to bill each assessment encounter or should we submit an aggregate of all assessment encounters with direct and non-direct work?
Providers should follow their normal billing practices as Mercy Care can administer either.