---
title: Mercy Care ABA coverage (AHCCCS plan).
url: "https://carelu.com/payers/mercy-care-arizona"
markdown_url: "https://carelu.com/payers/mercy-care-arizona.md"
state: AZ (Arizona)
payer: Mercy Care (AZ)
kind: Medicaid managed care plan (MCO)
parent_program: AHCCCS (Arizona Medicaid)
description: "How Mercy Care administers Arizona AHCCCS ABA — no PA on assessment codes, 6-month treatment authorizations on the plan's ABA PA form, Aetna Medicaid administration, the ACC + DDD + DCS triple footprint, and the TPL/COB quirks."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Mercy Care ABA coverage (AHCCCS plan).

_Payer Guide · Mercy Care · Last updated September 2026 · 6 primary sources_

> No PA on 97151/97152; 6-month auths on its own ABA form; serves ACC + DDD + DCS books.

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.

This plan administers the **AHCCCS (Arizona Medicaid)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [AHCCCS (Arizona Medicaid) guide](https://carelu.com/payers/arizona-ahcccs).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Not required for 97151 and 97152 — explicit on the plan's ABA page [1]
- **Prior auth for treatment**: Required for 97153–97158 — dedicated ABA PA form with clinical documentation; 6-month authorization periods [1][2]
- **Autism diagnosis required?**: No — clinical criteria defer to AMPM 320-S: ASD and/or other diagnoses as justified by medical necessity [3][1]

## At a glance

- **Plan type:** ACC + ACC-RBHA Central + DDD Health Plan + DCS CHP (Aetna Medicaid administration)
- **Clinical rules:** AMPM 320-S — the plan links the state policy as its criteria
- **Assessment PA:** None — 97151 and 97152 explicitly need no PA
- **Treatment PA:** Required for 97153–97158; 0362T/0373T are required billing codes
- **Auth periods:** 6 months — matching AMPM 320-S's 6-month progress-report cadence
- **Portal:** Availity, with a dedicated ABA PA form (initial + reauth)

## How Mercy Care runs ABA authorization

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]

## Three funnels, one payer — and the COB quirks

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]

## Intake gates

The questions that decide whether a family can start with Mercy Care (AZ), and what they have to bring.

- **Age limit**: 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]
- **Diagnosis recency**: 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]
- **Who may diagnose**: 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]
- **Diagnostic tools required**: 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]
- **Referral required?**: 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]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: 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]

## Delivery and billing rules

Coverage decides whether Mercy Care (AZ) pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: 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]
- **Bill as provider**: 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.
- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: 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. [3][2]

## What intake should collect for Mercy Care (AZ)

- **Which Mercy Care book:** ACC, Mercy Care DD (DDD/ALTCS), or DCS CHP (foster care) — same payer, different funnel and care team.
- **Diagnosis (any qualifying):** AMPM 320-S criteria — no autism dx strictly required; then book the assessment, no PA needed.
- **Other insurance:** 9715x codes bill primary first when other coverage exists — capture COB status up front (children 18 and under are paid primary per AHCCCS instruction).
- **Prior provider + active auths:** Ex-Action Behavior Centers / Centria families may arrive mid-authorization — get the history.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How Mercy Care (AZ) ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00841 — pVerify 00841 = "Mercy Care Arizona" (Elig Y). Related: 00842 "Mercy Care Plan (AHCCCS)", 06053 "Mercy Care RBHA".
- **Payer ID (Availity):** 86052 — Availity 86052 = "Mercy Care" (2012 list, but 86052 remains the current claims ID); Optum RTE = AEMED "Schaller Anderson Mercy Care".
- **Payer ID (Change Healthcare / Optum):** 86052
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** none (integrated — Aetna Medicaid Administrators)
- **ABA rides on:** medical benefit — BH integrated since 10/1/2018 (ACC) / 10/1/2019 (DDD); ABA rides medical on 86052 — no two-hop.
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Not required — assessment codes 97151/97152 are explicitly PA-exempt. | — | office/clinic, home (POS 12 — pays a ~10–11.5% premium on the AHCCCS schedule), school, community, telehealth (modality allowed under AMPM 320-S; ABA-specific POS/modifier not itemized) | — | HM (below bachelor's / BT-RBT), HN (bachelor's / BCaBA), HO (master's / BCBA), HP (doctoral / BCBA-D) |
| 97152 | Yes | Not required — assessment codes 97151/97152 are explicitly PA-exempt. | — | office/clinic, home (POS 12 — pays a ~10–11.5% premium on the AHCCCS schedule), school, community, telehealth (modality allowed under AMPM 320-S; ABA-specific POS/modifier not itemized) | — | HM (below bachelor's / BT-RBT), HN (bachelor's / BCaBA), HO (master's / BCBA), HP (doctoral / BCBA-D) |
| 97153 | Yes | Required — treatment codes require PA on the plan's ABA form/portal. | — | office/clinic, home (POS 12 — pays a ~10–11.5% premium on the AHCCCS schedule), school, community, telehealth (modality allowed under AMPM 320-S; ABA-specific POS/modifier not itemized) | — | HM (below bachelor's / BT-RBT), HN (bachelor's / BCaBA), HO (master's / BCBA), HP (doctoral / BCBA-D) |
| 97154 | Yes | Required — treatment codes require PA on the plan's ABA form/portal. | — | office/clinic, home (POS 12 — pays a ~10–11.5% premium on the AHCCCS schedule), school, community, telehealth (modality allowed under AMPM 320-S; ABA-specific POS/modifier not itemized) | — | HM (below bachelor's / BT-RBT), HN (bachelor's / BCaBA), HO (master's / BCBA), HP (doctoral / BCBA-D) |
| 97155 | Yes | Required — treatment codes require PA on the plan's ABA form/portal. | — | office/clinic, home (POS 12 — pays a ~10–11.5% premium on the AHCCCS schedule), school, community, telehealth (modality allowed under AMPM 320-S; ABA-specific POS/modifier not itemized) | — | HM (below bachelor's / BT-RBT), HN (bachelor's / BCaBA), HO (master's / BCBA), HP (doctoral / BCBA-D) |
| 97156 | Yes | Required — treatment codes require PA on the plan's ABA form/portal. | — | office/clinic, home (POS 12 — pays a ~10–11.5% premium on the AHCCCS schedule), school, community, telehealth (modality allowed under AMPM 320-S; ABA-specific POS/modifier not itemized) | — | HM (below bachelor's / BT-RBT), HN (bachelor's / BCaBA), HO (master's / BCBA), HP (doctoral / BCBA-D) |
| 97157 | Yes | Required — treatment codes require PA on the plan's ABA form/portal. | — | office/clinic, home (POS 12 — pays a ~10–11.5% premium on the AHCCCS schedule), school, community, telehealth (modality allowed under AMPM 320-S; ABA-specific POS/modifier not itemized) | — | HM (below bachelor's / BT-RBT), HN (bachelor's / BCaBA), HO (master's / BCBA), HP (doctoral / BCBA-D) |
| 97158 | Yes | Required — treatment codes require PA on the plan's ABA form/portal. | — | office/clinic, home (POS 12 — pays a ~10–11.5% premium on the AHCCCS schedule), school, community, telehealth (modality allowed under AMPM 320-S; ABA-specific POS/modifier not itemized) | — | HM (below bachelor's / BT-RBT), HN (bachelor's / BCaBA), HO (master's / BCBA), HP (doctoral / BCBA-D) |
| 0362T | Yes | Required — treatment codes require PA on the plan's ABA form/portal. | — | office/clinic, home (POS 12 — pays a ~10–11.5% premium on the AHCCCS schedule), school, community, telehealth (modality allowed under AMPM 320-S; ABA-specific POS/modifier not itemized) | — | HM (below bachelor's / BT-RBT), HN (bachelor's / BCaBA), HO (master's / BCBA), HP (doctoral / BCBA-D) |
| 0373T | Yes | Required — treatment codes require PA on the plan's ABA form/portal. | — | office/clinic, home (POS 12 — pays a ~10–11.5% premium on the AHCCCS schedule), school, community, telehealth (modality allowed under AMPM 320-S; ABA-specific POS/modifier not itemized) | — | HM (below bachelor's / BT-RBT), HN (bachelor's / BCaBA), HO (master's / BCBA), HP (doctoral / BCBA-D) |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** 6-month authorization periods; 0362T/0373T are required billing codes. AMPM 320-S covers ASD "and/or other diagnoses as justified by medical necessity" — no strict autism-dx requirement. Per-code daily unit caps are not published (AzCH uses hour bands, not caps).

### Medicaid rates

Source: Not separately published by Mercy Care. AHCCCS ACC/DDD plans are capitated, but ABA tracks the AHCCCS physician fee schedule (see arizona-ahcccs rates) as the public benchmark — Mercy Care's actual contracted rate is not published (and is NOT a statutory floor, unlike New Mexico). Effective 2023-11-01 (AHCCCS benchmark).

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | Benchmark: $30.06 (HN) / $35.78 (HO) / $44.73 (HP) office — see arizona-ahcccs | 15min | — |
| 97152 | Benchmark: $21.49 (HM) / $25.58 (HN) / $28.43 (HO/HP) office — see arizona-ahcccs | 15min | — |
| 97153 | Benchmark: $17.91 (HM) / $21.32 (HN) / $23.69 (HO/HP) office — see arizona-ahcccs | 15min | — |
| 97154 | Benchmark: $4.48 (HM) / $5.33 (HN) / $5.92 (HO/HP) office — see arizona-ahcccs | 15min | — |
| 97155 | Benchmark: $25.05 (HN) / $29.82 (HO) / $37.28 (HP) office — see arizona-ahcccs | 15min | — |
| 97158 | Benchmark: $6.26 (HN) / $7.46 (HO) / $9.32 (HP) office — see arizona-ahcccs | 15min | — |

### Contacts

- **Portal:** [Mercy Care Availity Provider Portal](https://www.mercycareaz.org/providers/portal.html)

Questions to ask on a verification call:

- Is there a daily or weekly unit cap for 97153–97155, and what capPeriod applies?
- Is telehealth allowed for ABA treatment codes, and if so what POS or modifier should I use?
- What POS codes (home, clinic, school, community) does Mercy Care actually accept on ABA claims?
- What’s the current authorized rate for 97156/97157, since they’re “By Report” at the state level?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://www.mercycareaz.org/providers/claims (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.optum.com/ (accessed 2026-07-23)
- https://www.azahcccs.gov/Resources/Downloads/EDIchanges/AZ270_271_CG.pdf (accessed 2026-07-23)
- https://www.mercycareaz.org/providers/applied-behavior-analysis.html (accessed 2026-07-23)
- https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/300/320S.pdf (accessed 2026-07-23)
- https://www.azahcccs.gov/AHCCCS/Downloads/PublicNotices/rates/FinalPublicNotice_RateChanges_20231101_ABA.pdf (accessed 2026-07-23)
- https://azahcccs.gov/PlansProviders/Downloads/FFSrates/ABA/FY26_Final_ABA_FeeSchedule.xlsx (accessed 2026-07-23)

## Common questions

### Does Mercy Care cover ABA therapy?

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.

### Is Mercy Care the same as Aetna?

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.

### How long do Mercy Care ABA authorizations last?

Six months, matching the state's 6-month progress-report cadence — build reauthorization requests from the AMPM 320-S progress report.

## Primary sources

1. [Mercy Care — Applied Behavior Analysis provider page](https://www.mercycareaz.org/providers/applied-behavior-analysis.html)
2. [Mercy Care — ABA PA request form](https://www.mercycareaz.org/content/dam/mercycare/pdf/PAabarequest_ua.pdf)
3. [AMPM 320-S — Behavior Analysis Services (AHCCCS)](https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/300/320S.pdf)
4. [azfamily — Nearly 1K Arizona children lose in-network ABA (3/5/2026)](https://www.azfamily.com/2026/03/05/nearly-1k-arizona-children-with-autism-lose-aba-therapy-coverage/)
5. [AHCCCS — Final Public Notice, FFS rate changes 11/1/2023 (ABA codes)](https://www.azahcccs.gov/AHCCCS/Downloads/PublicNotices/rates/FinalPublicNotice_RateChanges_20231101_ABA.pdf)
6. [Optum — Arizona AHCCCS Autism/ABA Program provider orientation (BH4129)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/azaba/azABA_Provider_Orient.pdf)
7. [Mercy Care — Provider Manual Ch. 100, General Terms (last updated July 2025)](https://www.mercycareaz.org/content/dam/mercycare/pdf/provider_manual_100_ua.pdf)
8. [AHCCCS — Prior Authorization Metrics for Medical Items and Services, CY2025 (3/31/2026)](https://www.azahcccs.gov/Resources/Downloads/PriorAuthorizationMetricAnnualReports/CMS_PA_Mandate_Report_Final_033026.pdf)
9. [42 CFR 438.210(d) — Medicaid managed care authorization decision timeframes](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-D/section-438.210)
10. [AHCCCS ACOM 434 — Coordination of Benefits and Third-Party Liability (eff. 5/2/2025)](https://www.azahcccs.gov/shared/Downloads/ACOM/PolicyFiles/400/434.pdf)
11. [32 CFR 199.8 — TRICARE double coverage (secondary to other plans, primary to Medicaid)](https://www.ecfr.gov/current/title-32/subtitle-A/chapter-VII/subchapter-M/part-199/section-199.8)
12. [VA — CHAMPVA Guidebook (updated 1/1/2025), CHAMPVA as secondary payer](https://www.va.gov/files/2025-12/CHAMPVA-Guidebook.pdf)

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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.