Provider Information

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).

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. 

Imagine more complete data . . .

  • New patient labs and records only a few clicks away
  • Real-time alerts when your high-needs patients are admitted or discharged from the hospital
  • Better coordination of patient care teams through secure electronic sharing of messages, notes and records

Sound good? That’s Why Mercy Care is partnering with Arizona’s Health Information Exchange

Mercy Care is partnering with Arizona’s statewide health information exchange (HIE). There are no participation fees and participation includes these key benefits:

  • One connection to save time and resources
    Making connections to other providers, hospitals, reference labs and health plans takes time and valuable resources from your practice. One connection saves time and allows real-time transfer of data from hospital encounters, reference lab results and other community provider encounters.
  • New patient information
    Connection to the HIE provides the ability to view current information and historical medical records in the HIE. Additionally, this information can be queried and downloaded to the electronic health record (EHR) of your practice.
  • Timely information to coordinate care
    Clinicians who participate in the statewide HIE can “subscribe” to a list of their high-need patients that they need to track closely. With information on more than 90% of hospital admissions, discharges and transfers (ADTs), the HIE can send a real-time notice of ADTS as well as lab results and transcribed reports.
  • Secure communication
    The use of the HIE’s DirectTrust-certified, HIPAA-compliant secure email system facilitates the easy and secure exchange of patient information between providers, care team members and healthcare facilities.

The following are the services available through the HIE:

  • Alert
    Notifications sent to designated clinicians or individuals based upon a patient panel. A patient panel is a practice or payer provided list of patients/members they wish to track. Alerts can be real-time or a daily/weekly summary. Alerts include:
    • Inpatient admission, discharge, transfer (ADT) Alerts
    • Emergency Department (ED) visit Alerts
    • Ambulatory Alerts – alerts your organization that a specific patient/member has been registered at an ambulatory facility or practice.
    • Clinical / Laboratory Test Result Alerts           
    • Patient Centered Data Home TM (PCDH) Alerts – ideal when treating patients who travel to other states.
  • Direct Email
    Secure email accounts that provide the means for registered users to exchange patient protected health information with other DirectTrust-certified email accounts. Direct Email is often used to receive Alerts.
  • Portal
    Secure web-based access that allows detailed patient data to be viewed through an online portal.
  • Data Exchange
    Electronic interfaces between patient tracking systems and the HIE. Data exchange services include:
    • Unidirectional Exchange
    • Bidirectional Exchange
  • Clinical Summary
    A comprehensive Continuity of Care Document (CCD) containing up to 90 days of the patient’s most recent clinical and encounter information. Clinical Summaries include:
    • Automated Clinical Summary             
    • Query/ Response Clinical Summary 
    • Patient Centered Data Home Clinical Summary

For more information on the HIE Services, visit www.healthcurrent.org/hieservices.

To support inpatient concurrent review decisions, Mercy Care uses nationally-recognized and/or community-developed, evidence-based criteria, which are applied based on the needs of individual members and characteristics of the local delivery system.

Service authorization staff that make medical necessity determinations are trained on the criteria and the criteria are accepted and reviewed according to Mercy Care policies and procedures.

Criteria sets are reviewed annually for appropriateness to the Mercy Care population needs and updated as applicable when nationally or community-based clinical practice guidelines are updated.  The annual review process involves appropriate practitioners in developing, adopting, or reviewing criteria. 

The criteria are consistently applied, considering individual needs of the members and allow for consultations with requesting practitioners/providers when appropriate. For inpatient medical care reviews, Mercy Care uses the following medical review criteria in the order listed:

  • Criteria required by applicable state or federal regulatory agency
  • Applicable MCG as the primary decision support for most clinical diagnoses and conditions
  • Aetna Clinical Policy Bulletins (CPB’s), 
  • Aetna Clinical Policy Council Review (ad hoc)

For inpatient behavioral health care reviews, MCP uses, in the order listed:

  • Criteria required by applicable federal and state regulatory agency
  • MCG, ASAM PPC-2R, CASII, LOCUS
  • Aetna Clinical Policy Bulletins (CPBs)
  • Aetna Clinical Policy Council Review (ad hoc)