Mercy Care — administered by Aetna Medicaid Administrators LLC — is the widest single payer relationship in Arizona Medicaid ABA: it holds an ACC contract, the ACC-RBHA Central GSA contract, one of the two statewide DDD Health Plans (Mercy Care DD), and the DCS Comprehensive Health Plan for children in foster care. Clinically it runs no separate medical-necessity policy — its ABA page links AMPM 320-S as the criteria — but operationally it is distinct: an explicit no-PA rule on assessment codes, 6-month authorization blocks on its own ABA PA form, and third-party-liability quirks worth knowing before the first claim.
Assessments start without authorization — the plan's ABA page says directly that you don't need PA for adaptive behavior assessment codes 97151 and 97152 — so eligibility verification can flow straight into a booked assessment. Treatment codes 97153–97158 require PA, and payment may be denied for services delivered without it. Requests go on Mercy Care's dedicated ABA PA form (initial and reauthorization versions) with the required clinical documentation, through the Availity portal, and authorizations run 6 months at a time — deliberately aligned with AMPM 320-S's minimum 6-month progress-report requirement, so build the reauth packet from the progress report you already owe the state. The child and family team (CFT) — or adult recovery team — determines medically necessary services, so expect care-team coordination rather than a pure paper review.[1][2]
A Mercy Care contract touches three distinct member populations: ACC members, DDD/ALTCS members via Mercy Care DD, and foster-care children via the DCS Comprehensive Health Plan — one credentialing relationship, three intake funnels. Two billing quirks matter at intake. First, coordination of benefits: the 9715x CPT codes require billing primary insurance first when the member has other coverage (unless the service is non-covered or benefits are exhausted — noted on the PA form), while H/S/T-prefixed codes bypass COB internally. Second, the child-friendly exception: per AHCCCS instruction, approved children's services (18 and younger) are reimbursed at a primary level with post-adjudication reclamation — claims aren't denied for a missing primary EOB. And note the March 2026 network purge: Mercy Care terminated its Action Behavior Centers and Centria contracts, so displaced families are actively looking for in-network providers.[1][4]
The questions that decide whether a family can start with Mercy Care (AZ), and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the AHCCCS rule — Mercy Care runs no separate medical-necessity policy and links AMPM 320-S as its criteria: AMPM 320-S sets no age bound of its own. Behavior Analysis Services are covered "for individuals with Autism Spectrum Disorder (ASD) and/or other diagnoses as justified by medical necessity," and the policy applies across ACC, ALTCS E/PD, DCS/CMDP, DES/DDD, the RBHA contracts and fee-for-service programs without an age criterion. In practice children reach the benefit through EPSDT, and nothing in the policy text excludes adults — screen on medical necessity, not birthday.[3][1]
Follows the AHCCCS rule — Mercy Care runs no separate medical-necessity policy and links AMPM 320-S as its criteria: None at the state level. AMPM 320-S imposes no recency clock on the diagnostic evaluation — and no autism diagnosis at all is strictly required. What must be current is the assessment: services are "prescribed or recommended in specific dosages, frequency, intensity, and duration by a qualified BHP as the result of an assessment of the member." Plan-level overlays can be stricter, so check the per-plan guide before telling a family an old evaluation still counts.[3][1]
Follows the AHCCCS rule — Mercy Care runs no separate medical-necessity policy and links AMPM 320-S as its criteria: AMPM 320-S gates on who recommends ABA, not on who diagnoses: services must be "prescribed or recommended... by a qualified BHP." A Behavioral Health Professional is defined as an individual licensed under A.R.S. Title 32, Chapter 33 whose scope allows independent behavioral health practice (or practice under direct supervision, except a licensed substance abuse technician); a psychiatrist (A.R.S. § 36-501); a psychologist (A.R.S. § 32-2061); a physician; a Behavior Analyst (A.R.S. § 32-2091); a registered nurse practitioner licensed as an adult psychiatric and mental health nurse; or a registered nurse with psychiatric-mental health certification or one year of behavioral health experience.[3][1]
Follows the AHCCCS rule — Mercy Care runs no separate medical-necessity policy and links AMPM 320-S as its criteria: No single instrument is mandated. "Behavior Analysis Services shall be based upon assessment(s) that include Standardized and/or Non-standardized instruments through both direct and indirect methods." Standardized examples named in the policy: the Pervasive Developmental Disabilities Behavior Inventory, the Brigance Inventory of Early Development and the Vineland Adaptive Behavior Scales. Non-standardized examples: curriculum-referenced assessments and stimulus preference assessment procedures.[3][1]
Follows the AHCCCS rule — Mercy Care runs no separate medical-necessity policy and links AMPM 320-S as its criteria: a prescription or recommendation from a qualified Behavioral Health Professional, based on an assessment of the member. On top of that the plan states no prior authorization is needed for adaptive behavior assessment codes 97151 and 97152, while treatment codes 97153–97158 require PA on Mercy Care's own ABA PA form through Availity, in 6-month authorization blocks. The child and family team determines medically necessary services, so expect care-team coordination rather than a pure paper review.[1][2][3]
Mercy Care’s manual: "The authorization decision must be made within 14 calendar days from the date of receipt of the service request"; expedited within 72 hours, and if that deadline falls on a weekend or holiday the decision is due the day before. ABA treatment (97153–97158) needs PA, assessments 97151/97152 do not, and an approved authorization runs "a maximum for 6 months, re-authorization will be required" on the same ABA PA form, built on the six-month reassessment. No reauth lead time is published. AHCCCS’s own CY2025 prior-authorization metrics report (March 2026) says that "Beginning January 1, 2026" the CMS rule requires Medicaid managed care plans to decide within "7 calendar days for standard requests (non-urgent)" and "72 hours for expedited requests (urgent)"; the federal regulation ties the 7-day ceiling to rating periods starting on or after January 1, 2026. Mercy Care’s July 2025 manual predates that, so confirm which clock it runs.[7][2][8][9]
Mercy Care answers the secondary-PA question on its ABA page: "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 applies on the PA form. For children, 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" — send the primary EOB with each claim, but claims are not denied for it. Otherwise bill the primary first (H/S/T codes bypass COB). On a family’s commercial copays and deductibles Mercy Care pays the lesser of the primary’s member cost share or the gap to your contracted rate. Under federal rules TRICARE pays before Medicaid, and CHAMPVA pays first when the child is also Medicaid-eligible.[1][7][10][11][12]
Follows the AHCCCS rule — Mercy Care runs no separate medical-necessity policy and links AMPM 320-S as its criteria: AMPM 320-S permits telehealth delivery but does not price it: the individualized treatment plan must "identify the modality by which the service will be delivered (whether in person or via telehealth, or in-group or individual setting, or combination thereof)." Which 9715x codes are actually payable remotely, and with which place-of-service code or modifier, lives in the AHCCCS telehealth code set and the Behavioral Health Services Billing Matrix, neither of which we could retrieve at this review — azahcccs.gov returns 403 to automated fetching.[3][1]
Blocked on: Mercy Care provider services / Availity, and the AHCCCS Telehealth code set (azahcccs.gov blocked automated retrieval at this review; mercycareaz.org returns 403).
Coverage decides whether Mercy Care (AZ) pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Follows the AHCCCS rule — Mercy Care runs no separate medical-necessity policy and links AMPM 320-S as its criteria: A duty with no number attached. "Behavior Analysis Services shall be directed and overseen by Behavior Analysts and supported, where applicable, by Behavior Analysis Trainees and/or Behavior Technicians." The Behavior Analyst "is responsible for all aspects of clinical direction, supervision, and provider-level case management," for training Trainees and Technicians, for ensuring that "the extent, kind, and quality" of what they deliver matches their training and experience, and for their compliance with the policy and A.R.S. § 32-2091. A Behavior Analysis Trainee needs "direct and ongoing supervision consistent with the standards set by a nationally recognized Behavior Analyst certification board." AMPM 320-S publishes no supervision percentage and no caseload cap, so for RBT-credentialed staff the BACB floor is the operative number.[3][1]
Follows the AHCCCS rule — Mercy Care runs no separate medical-necessity policy and links AMPM 320-S as its criteria: The claim line has to say who actually delivered the service. AHCCCS pays credential-tiered rates through modifiers — HM below bachelor's (technician level), HN bachelor's, HO master's, HP doctoral — and AMPM 320-S points to the Behavioral Health Services Billing Matrix for "modifiers for Behavior Analysis Trainee billing." Whose NPI goes in the rendering field is set per Contractor: UnitedHealthcare Community Plan, for instance, requires the rendering provider's 10-digit NPI in box 24J, "must be an active AHCCCS registered provider (The rendering provider is the BCBA/Licensed Clinician)."[3][5][6][2]
Ask the plan: Mercy Care provider services and the plan's ABA PA form / Availity; mercycareaz.org returned 403 to automated retrieval at this review, so plan-level specifics could not be re-read.
Follows the AHCCCS rule — Mercy Care runs no separate medical-necessity policy and links AMPM 320-S as its criteria: AMPM 320-S does not address whether 97153 and 97155 may be billed for the same clock time. The policy routes every coding question elsewhere: "Refer to the Behavioral Health Services Billing Matrix and Medical Coding Resources on the AHCCCS website for more information regarding required coding information, including covered settings, modifiers for Behavior Analysis Trainee billing, or other billing/coding information."[3][2]
Blocked on: Mercy Care provider services and the plan's ABA PA form / Availity; mercycareaz.org returned 403 to automated retrieval at this review, so plan-level specifics could not be re-read.
Follows the AHCCCS rule — Mercy Care runs no separate medical-necessity policy and links AMPM 320-S as its criteria: No per-day unit ceiling appears in AMPM 320-S; the policy sets clinical content, not claim edits, and defers unit and coding questions to the Behavioral Health Services Billing Matrix. Dosage is set case by case — services are prescribed "in specific dosages, frequency, intensity, and duration" by the recommending BHP — so the binding ceiling in practice is the Contractor's authorization.[3][2]
Blocked on: Mercy Care provider services and the plan's ABA PA form / Availity; mercycareaz.org returned 403 to automated retrieval at this review, so plan-level specifics could not be re-read.
Follows the AHCCCS rule — Mercy Care runs no separate medical-necessity policy and links AMPM 320-S as its criteria: AMPM 320-S sets a reporting cadence, not a signature rule. Progress reports are required "at minimum, every six months" and must include member identification; background information (family dynamics, school placement, cultural considerations, prenatal and/or developmental history, medical history, sensory, dietary and adaptive needs, sleep patterns, medications); assessment findings; outcomes (measurable objectives, progress toward goals, clinical recommendations, treatment dosage, family role and outcomes); and care coordination (transition statement and individualized discharge criteria). Who signs a session note, and within what window, is not stated.[3][2]
Blocked on: Mercy Care provider services and the plan's ABA PA form / Availity; mercycareaz.org returned 403 to automated retrieval at this review, so plan-level specifics could not be re-read.
Follows the AHCCCS rule — Mercy Care runs no separate medical-necessity policy and links AMPM 320-S as its criteria: AMPM 320-S requires the treatment plan to "specify the setting(s) in which services will be delivered" but publishes no payable-setting list, pointing instead to the Behavioral Health Services Billing Matrix "regarding required coding information, including covered settings." What is documented at the rate level is that setting changes the money: the November 2023 fixed-rate notice pays home delivery (POS 12) roughly 10% above the clinic rate on every ABA code.[3][5][2]
Blocked on: Mercy Care provider services and the plan's ABA PA form / Availity; mercycareaz.org returned 403 to automated retrieval at this review, so plan-level specifics could not be re-read.
Yes — on AMPM 320-S criteria (the plan links the state policy directly). Assessment codes 97151/97152 need no PA; treatment codes 97153–97158 require PA on the plan's ABA form, in 6-month authorization periods.
Mercy Care is administered by Aetna Medicaid Administrators LLC, so the machinery is Aetna's — but it's a Medicaid plan on AHCCCS rules, not Aetna's commercial CPB 0554 policy. A family saying "we have Aetna" in Phoenix may well be a Mercy Care member.
Six months, matching the state's 6-month progress-report cadence — build reauthorization requests from the AMPM 320-S progress report.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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