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.

You can view or download the results of the Mercy Care member and provider surveys:

Arizona Health Care Cost Containment System (AHCCCS) consumer surveys - AHCCCS conducts Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys on a regular basis to better understand member satisfaction with the contracted Managed Care Organizations (MCOs) and/or member satisfaction with the overall AHCCCS healthcare delivery system.

You can also view the following AHCCCS Member Satisfaction Surveys on the AHCCCS website: Member Survey Results, Provider Survey Results, Performance Measure Results and AHCCCS Performance Measures.

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, Mercy Care 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)

Housing

What is Permanent Supportive Housing?

Permanent Supportive Housing is housing that is decent, safe, affordable and integrated into the community. It's linked to flexible supports to help people be successful in maintaining their housing.

How does Permanent Supportive Housing help tenants?

The Permanent Supportive Housing approach is a belief that people with psychiatric disabilities should have the right to live in a home of their choice, on their own, without any special rules or service requirements. They can live just like any other member of the community.

Programs take different approaches to housing. In some, people live in units reserved for the program’s tenants, among those with and without special needs. In others, people receive help finding, qualifying for, and keeping their homes, which are located throughout the community.

All tenants have access to an array of services that help them keep their housing, such as case management, assistance with daily activities, conflict resolution, and crisis response. Tenants also receive help in becoming fully participating members of the community, through assistance with socialization and seeking employment.

How does Permanent Supportive Housing work?

  • Flexible, voluntary supports: Permanent Supportive Housing staff offers flexible, voluntary services designed to help people choose housing that meets their needs, obtain and pay for that housing, and keep the housing for as long as they choose.
  • Quality housing: Housing meets standards for safety and quality established by local, state, and federal laws and regulations. Housing is similar to what is available to others in the same income levels in the community.
  • Rental assistance or Standard lease: Tenants typically pay 30 percent of their income toward rent plus basic utilities. The remainder is paid either by tenant-based rental assistance, which tenants can use in housing of their choice, or project-based rental assistance, which is linked to a specific location.
  • Functional separation of housing and supports: Tenants sign a standard lease, just like any other member of the community, giving tenants the same legal rights. Continued tenancy is not subject to any special rules or participation in any particular services.
  • Integration: Tenants’ homes are located throughout the community or in buildings in which a majority of units are not reserved for people with disabilities. Tenants have opportunities for interactions with the community.

For more information: Contact Mercy Care RBHA's Housing Department at housing@mercycareaz.org

AHCCCS Housing Program 

Q: What is the AHCCCS Housing Program (AHP)? 

The AHP is a statewide permanent supportive housing and housing support program for individuals with mental health diagnoses who are experiencing homelessness. 

 

Q: In October, what happens to my members on the waitlist with Mercy Care? 

Members will not be removed from the current waitlist, and Mercy Care will be providing the waitlist to ABC. 

 

Q: Will there still be the Community Living, Scattered Site, and Bridge to Permanency programs?  

The current housing programs will continue with the transition to the AHP. 

 

Q: Will my members’ supportive services be impacted by the transition to the AHP?  

Mercy Care will continue to oversee all Permanent Supportive Housing services and services connected to the Community Living Program. 

 

Q: Is FlexCare transitioning to the AHP? 

Mercy Care will continue to manage the applications, waitlist, and referrals and provide oversight to FlexCare providers.  FlexCare is not transitioning to the AHP. 

  

Q: Is the TLP transitioning to the AHP? 

No, the TLP is not transitioning to the AHP and Mercy Care will continue to manage the applications, waitlist, and referrals. 

 

Q: Does the AHP impact BHRF (Behavioral Health Residential Facility)? 

No, BHRF is not transitioning to the AHP, and Mercy Care will continue to manage the applications, waitlist, and referrals. 

 

Q: Will Mercy Care participate in staffings for members housed with the AHP? 

Yes, Mercy Care will continue to be involved in staffings as needed to support our members in housing. 

 

Q: Are the eligibility requirements the same with the AHP? 

Eligibility requirements will be available in the ACOM 448 Policy. They have changed slightly. They will also be included in provider training.  

According to the AHCCCS Permanent Supportive Housing Guidebook and Operations Manual draft, applicants shall: 

  • Be determined SMI or GMH/SU with High/Cost Needs by a qualified provider. 
  • Be a United States citizen or have eligible immigrant status. 
  • Be at least 18 years old. 
  • Have an identified housing need documented by the member’s clinical provider or treatment team. Identified housing needs include members in the following situations: 
    • Persons Experiencing Homelessness. 
    • Medical or behavioral health transitions requiring placement in safe, adequate housing placement per AMPM 520. 
    • Medical necessity as determined by a qualified representative of a provider or MCO. 

Q: Will the prioritization for referrals be the same with the AHP? 

Prioritization requirements will be available in the AHCCCS Supportive Housing Guidebook and Operations Manual.  Prioritization has changed slightly. This will also be included in provider training.  

According to the AHCCCS Permanent Supportive Housing Guidebook and Operations Manual draft, prioritization criteria include VI-SPDAT or other Objective Acuity Score, Cost and Medical/Behavioral Health Need, and Homeless Status. 

Q: How will members apply for housing with the AHP?  Are application requirements the same? 

Members will apply for housing through their behavioral health provider. BH providers will submit applications to ABC/HOM for processing.  

As of October 2021, applications will be submitted via email to AHPapplications@azabc.org. 

Q: Who can I contact with questions related to my member’s housing, including questions about rent and maintenance?  

Please contact ABC/HOM for questions related to member rent, lease, or housing subsidy. For questions about services related to housing please contact the member’s behavioral health provider. For questions about maintenance of the member’s unit please contact their landlord. ABC and their behavioral health provider may be able to help provide additional assistance with talking to their landlord and may also be able to help with maintenance requests.  

If members receive any notices from their landlords, please contact ABC and their behavioral health provider for assistance in resolving an issue.  

After October 1, 2021, ABC can be outreached via email.  Additional information to be provided. 

For more information on the AHP, you can visit the following websites:

Q:  What is the Temporary Housing Assistance Program (THAP)? 

This program provides temporary financial assistance, combined with Permanent Supportive Housing services and Supported Employment services to members determined to have a serious mental illness (SMI) who need temporary assistance to prevent homelessness. 

Mercy Care RBHA has contracted with COPA Health and La Frontera/EMPACT to provide the Temporary Housing Assistance Program to a minimum of 300 members threatened with facing eviction or precariously housed in the community. This program will provide time-limited financial support for eviction prevention activities that include, but are not limited to: back rent, late utilities, moving assistance and deposits.  As of October 2021, the financial support for the THAP will be managed by the AHP Administrator, Arizona Behavioral Health Corporation.  Permanent Supportive Housing and Supported Employment services will be overseen by Mercy Care. 

The Permanent Supportive Housing services and Supported Employment services continue to support the member's ongoing success in housing. 

Referrals to the Temporary Housing Assistance Program are made by the clinical team to the service provider. Contact information for each provider is listed below. 

La Frontera/Empact: Angela Sheesley, Program Manager, 480-784-1514, Angela.Sheesley@lafrontera-empact.org.

COPA Health: Ebbonie Montague, 480-589-4835, ebbonie.montague@copahealth.org 

Q:  What Permanent Supportive Housing does Mercy Care RBHA offer? 

Permanent Supportive Housing includes housing subsidies and/or supportive services.  

As of October 2021, the PSH subsidies will be managed by the AHCCCS Housing Program administrator, Arizona Behavioral Health Corporation (ABC).  The Scattered Site program provides housing subsidies that can be used in the community.  The tenant pays 30 percent of his/her income toward rent.  

Community Housing is a Permanent Supportive Housing option that includes apartments and houses from an inventory of housing. Some of these Community Housing locations are specialized for individuals with unique needs.  

Permanent Supportive Housing services are available to all tenants, regardless of their housing location. The primary goal of the Supportive Housing Services is to assist the member to maintain permanent housing in the community of his/her choice. 

Q:  What if a member already has housing, but wants Supportive Housing Services? 

  • The clinical team can reach out to one of the eight Permanent Supportive Housing service providers to request services for a member.  Services are available for members seeking housing and for members currently living independently. 

The Permanent Supportive Housing service providers: 

 

Q:  What type of services will the member receive in Permanent Supportive Housing? 

  • The services are person-centered and focused on assisting the member to live independently and maintain housing. Services may include education on tenant rights, case management, financial management and budgeting, communication skills, safety and hazard recognition, health and wellness, accessing community resources and others.  Services are individualized and can last as long as the member requires support to maintain housing. 

Q: How long will services last? 

  • Services are individualized and can last as long as the member requires support to maintain housing. 

Source: Substance Abuse and Mental Health Services Administration Supportive Housing brochure (PDF) (PDF) (12/3/2014)