---
title: Banner-University Family Care ABA coverage (AHCCCS plan).
url: "https://carelu.com/payers/banner-university-family-care"
markdown_url: "https://carelu.com/payers/banner-university-family-care.md"
state: AZ (Arizona)
payer: Banner-University Family Care
kind: Medicaid managed care plan (MCO)
parent_program: AHCCCS (Arizona Medicaid)
description: "How Banner-University Family Care handles Arizona AHCCCS ABA — the AMPM 320-S state baseline, the plan's ABA Prior Authorization Form, the 10-county ACC + ALTCS footprint, and the specifics you'll need to verify in the Banner portal."
last_reviewed: October 2026
vob_data_updated: 2026-10-15
---

# Banner-University Family Care ABA coverage (AHCCCS plan).

_Payer Guide · Banner-University Family Care · Last updated October 2026 · 24 primary sources_

> AMPM 320-S baseline; PA on 97155–97158 (assessment and 97153/97154 PA-free in network); 120-day filing limit.

Banner-University Family Care — the Banner Health / University of Arizona Health Plans entry — carries the second-largest ACC footprint (ten counties, including Maricopa and Pima) plus ALTCS contracts. Unlike Mercy Care, UHC, or Arizona Complete Health, Banner publishes no distinct ABA clinical policy: everything we can verify points to the AMPM 320-S state baseline plus the plan's own ABA Prior Authorization Form. That makes this a verify-in-the-portal plan — the state guide tells you the clinical rules; Banner's portal tells you the paperwork.

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 for in-network providers — Banner’s 2026 manual lists 97151 and 97152 under prior authorization for “Non-Par only”; an out-of-network provider needs PA for the assessment [6]
- **Prior auth for treatment**: Required for 97155, 97156, 97157 and 97158 before services start, on Banner’s ABA Prior Authorization Form faxed to 520-694-0599; 97153 and 97154 need PA “only if Out of Network” (2026 manual). Durations are not published [6][7]
- **Autism diagnosis required?**: No distinct plan policy published — AMPM 320-S baseline applies (autism dx not strictly required) [8][7]

## At a glance

- **Plan type:** ACC in 10 counties + ALTCS (Banner Health / UA Health Plans)
- **Clinical rules:** No distinct published ABA policy — AMPM 320-S baseline
- **Treatment PA:** Required for 97155–97158 (97153/97154 only out of network) — Banner ABA PA form
- **Assessment PA:** Not required in network — 97151/97152 need PA for non-par providers only
- **Timely filing:** 120 days from DOS (contracted, unless your contract differs); resubmissions 1 year
- **Portal:** bannerhealth.com/bhpprovider (Banner Health Plans provider portal)
- **Rates:** Not published — AHCCCS physician fee schedule is the benchmark

## What's verified — and what to pull from the portal

Banner lists an "Applied Behavior Analysis (ABA) Prior Authorization Form" among its behavioral-health materials, and its 2026 provider manual (effective 7/9/2026) says which codes it covers. “ABA Codes that require Prior Authorization: 97155, 97156, 97157, 97158 (97153, 97154, only if Out of Network)”; the assessment codes 97151 and 97152 are listed for PA as “Non-Par only.” Requests go by fax to 520-694-0599 with the ABA PA form and “All documentation listed on the ABA PA form,” before services start. The plan publishes no ABA clinical policy, no authorization durations and no hour guidance, so the clinical rules are the state baseline: AMPM 320-S criteria (including the no-autism-dx-required rule and 6-month progress reports). [7][6][8]

## Footprint

Banner-University Family Care operates as an ACC plan in Maricopa, Pinal, Cochise, Gila, Graham, Greenlee, La Paz, Pima, Santa Cruz, and Yuma counties, plus ALTCS in ten counties — the second-largest geographic reach after Arizona Complete Health. For intake, that means Banner cards show up across both metro Phoenix and southern Arizona; treat every one as an AMPM 320-S case with Banner-specific paperwork to confirm. [9]

## Can an out-of-state BCBA treat an Arizona member, including by telehealth?

Arizona licenses the practice: “A person who wishes to practice as a behavior analyst must be licensed pursuant to this article” (A.R.S. § 32-2091.02, Board of Psychologist Examiners), and practicing unlicensed is a class 2 misdemeanor (§ 32-2091.12). Arizona is unusual in giving out-of-state clinicians a telehealth-only route: under A.R.S. § 36-3606 a health care provider “who is not licensed in this state may provide telehealth services to a person located in this state” after registering with the board that licenses the comparable profession, holding “a current, valid and unrestricted license to practice in another state that is substantially similar,” carrying malpractice coverage that includes Arizona telehealth, and following Arizona’s scope and standard-of-care rules. Behavior analysts are licensed under Title 32, chapter 19.1, which § 36-3601 includes in the definition of “health care provider.” A registered provider may not open an Arizona office (except within a multistate group that includes an Arizona-licensed provider) or see Arizona patients in person without an Arizona license. Fewer than ten telehealth encounters a year, or care in consultation with an Arizona-licensed provider who keeps ultimate authority, is exempt from registration. [13][14][15][16][8][17][18]

AHCCCS ties ABA to the Arizona license: AMPM Policy 320-S defines a Behavior Analyst as “A person who is licensed pursuant to A.R.S §32-2091,” and A.R.S. § 32-2091.14 directs AHCCCS to recognize “a behavior analyst who is licensed pursuant to this article” as a behavioral health professional eligible for reimbursement. A § 36-3606 telehealth registration is not that license, so for AHCCCS work plan on full Arizona licensure. [13][14][15][16][8][17][18]

Federal rules make the state Medicaid enrollment rule binding on the plan: the state “must screen and enroll, and periodically revalidate, all network providers” of Medicaid managed care plans (42 CFR 438.602(b)(1)). So a BCBA in Banner-University Family Care’s network has to be enrolled with AHCCCS as well. [13][14][15][16][8][17][18]

## Can Banner-University Family Care authorize ABA retroactively?

Only at the plan’s discretion for good cause. B–UFC’s 2026 manual: “A Retrospective Review request will be considered at the plan discretion when good cause is demonstrated why pre-service authorization did not occur prior to services being rendered.” Submit the Retrospective Review Request Form, explaining why authorization was not obtained, batched with the claim and within B–UFC’s claim submission guidelines; B–UFC decides within 30 days of receipt. [6]

## Claims: filing deadline, disputes and EVV

Six months to file, twelve to get it clean. A.R.S. § 36-2904(G) bars AHCCCS from paying a claim “initially submitted more than six months after the date of the service for which payment is claimed or after the date that eligibility is posted, whichever date is later,” or one not submitted as a clean claim within twelve months — and the same subsection applies the identical limits to the health plans that contract with AHCCCS, so Banner–University Family Care cannot pay a claim outside those windows either. The FFS billing manual restates it: a claim first received inside six months has until twelve months from the date of service to reach clean-claim status or be adjusted, after which “AHCCCS is not liable for payment.” [19][20][6][5][21][22][23]

Banner’s own clock is shorter. B – UFC’s 2026 manual: providers “must submit all claims for covered services provided to members within one hundred and twenty (120) days after the Covered Services are rendered,” and “Unless another timeframe is specified in your contract, claims initially received more than 120 days from the date of service will be denied”; non-contracted providers get six months. Resubmissions (replacements) “must be received within one (1) year from the date of discharge or date of service,” marked as a resubmission with the original claim number in box 22 (loop 2300 REF02 electronically). Secondary claims need the primary payer’s remittance advice and must arrive “within 60 days of the primary payer’s remittance advice” (non-contracted providers: 60 days from that remittance or six months from the date of service, whichever is greater). [19][20][6][5][21][22][23]

Payment. “The Claims Department will adjudicate all properly submitted, authorized claims that meet ‘clean claims criteria’ within 45 days of receipt unless otherwise stipulated in your contract.” Banner asks providers to allow 14 days after submission before checking claim status and 60 days before resubmitting. AHCCCS ACOM 203 binds the plan “unless a subcontract specifies otherwise”: 95% of clean claims adjudicated within 30 days of receipt and 99% within 60, with interest at 10% a year from the 46th day on a non-hospital clean claim paid after 45 days. Banner publishes no weekly submission cutoff or check-run day. [19][20][6][5][21][22][23]

Disputes. AHCCCS requires claim disputes in writing within twelve months of the date of service, twelve months of the date eligibility is posted, or sixty days after the denial of a timely claim, whichever is later (A.R.S. § 36-2903.01(B)(4); A.A.C. R9-34-401 et seq.). Disputes for fee-for-service members go to AHCCCS’s Office of General Counsel (or through the AHCCCS Solutions Center); for Banner–University Family Care members the dispute is filed with Banner–University Family Care. An unfavourable Notice of Decision can be taken to a state fair hearing within 30 days of receipt. [19][20][6][5][21][22][23]

EVV. AMPM 540 (revised effective 08/06/26) applies Electronic Visit Verification to “personal care and home health services” under 42 U.S.C. 1396b(l), for ACC, DDD and fee-for-service alike, and AHCCCS’s EVV page names those services as attendant care, personal care, homemaker, habilitation, respite and in-home skilled nursing. ABA is not among them. A visit is subject to EVV only when the provider type, the service code and the place of service all match AHCCCS’s published list, so an agency that also bills habilitation in the home should check that list. [19][20][6][5][21][22][23]

## Intake gates

The questions that decide whether a family can start with Banner-University Family Care, and what they have to bring.

- **Age limit**: Follows the AHCCCS rule — Banner publishes no distinct ABA clinical policy, only its own ABA Prior Authorization Form: 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. [8][7]
- **Diagnosis recency**: Follows the AHCCCS rule — Banner publishes no distinct ABA clinical policy, only its own ABA Prior Authorization Form: 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. [8][7]
- **Who may diagnose**: Follows the AHCCCS rule — Banner publishes no distinct ABA clinical policy, only its own ABA Prior Authorization Form: 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. [8][7]
- **Diagnostic tools required**: Follows the AHCCCS rule — Banner publishes no distinct ABA clinical policy, only its own ABA Prior Authorization Form: 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. [8][7]
- **Referral required?**: Follows the AHCCCS rule — Banner publishes no distinct ABA clinical policy, only its own ABA Prior Authorization Form: A prescription or recommendation from a qualified Behavioral Health Professional, based on an assessment of the member, is the referral — AMPM 320-S requires nothing else and sets no prior-authorization rules of its own, leaving PA to the Contractors. The two largest plans both skip PA on the assessment codes: Mercy Care states no PA is needed for 97151 and 97152, and Optum's Arizona orientation states "All ABA services require prior authorization except 97151 and 97152." [8][10][11][7]
- **Telehealth**: Banner’s 2026 manual adds no ABA telehealth coding of its own (it requires informed consent before telehealth under AMPM 320-I and exempts telehealth visits from EVV), so the rule is the AHCCCS rule: AMPM 320-I binds ACC, ALTCS and DDD Contractors by its own terms. All eight ABA CPT codes (97151–97158) are on the AHCCCS Telehealth Code Set (sheet effective 06/01/2026) for interactive audio-video with the GT modifier; none carries the audio-only FQ modifier, and 0362T and 0373T are not listed. The place of service on the claim is the originating site, where the member is (12 home, 03 school, 11 office): “AHCCCS will not be utilizing POS 02 and POS 10 for telehealth” unless another primary payer requires them. AMPM 320-S requires the treatment plan to “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),” so name telehealth in the plan you submit for authorization. [4][3][8][6]
- **Prior-auth decision time**: Banner – UFC’s 2026 manual: "Medical Standard requests will be reviewed within 14 days. Medical Expedited requests will be reviewed within 72 hours of receipt," and "Extensions on expedited and standard requests can be provided if more time is needed to obtain records." ABA PA is required before services begin, faxed on Banner’s ABA PA form; 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. Confirm with Banner which clock it runs. [6][25][26]
- **Other insurance (who pays first)**: Banner – UFC pays last: it "will require an Evidence of Benefit (EOB) or Remit Advice (RA) from a primary payer to coordinate benefits once the primary payer has adjudicated the claim" and "may further review the claim for medical necessity" on its own criteria; "If primary payor does not cover the service, B – UFC may waive the need for an EOB or RA." Cost sharing is paid up to the lesser of its fee schedule or the other payer’s allowed amount, and secondary claims are due within 60 days of the primary RA. The manual does not say whether Banner requires its own PA when secondary; AHCCCS policy (ACOM 434) bars a secondary PA only when the other insurer approved the service as medically necessary, so where the commercial plan has not approved ABA, get Banner’s PA. Under federal rules TRICARE pays before Medicaid, and CHAMPVA pays first when the child is also Medicaid-eligible. [6][27][28][29]

## Delivery and billing rules

Coverage decides whether Banner-University Family Care 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 — Banner publishes no distinct ABA clinical policy, only its own ABA Prior Authorization Form: 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. [8][7]
- **Bill as provider**: Follows the AHCCCS rule — Banner publishes no distinct ABA clinical policy, only its own ABA Prior Authorization Form: 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)." [8][12][11][7]
- **Daily limits / MUEs** _(plan-dependent)_: No per-day unit cap is published. AMPM 320-S sets none, and Banner’s 2026 provider manual lists no ABA unit limits, so the authorization is the ceiling for the codes that need one (97155–97158, and 97153/97154 out of network). CMS makes the Medicaid NCCI unit edits “desirable but optional” for managed care plans (the public Medicaid MUE for 97153 is 32 units per claim line), and Banner’s manual does not say whether it applies them. [8][6][2][1]
  - Ask the plan: Banner Health Plans provider services — ask whether Medicaid MUEs are applied to ABA claim lines, and check the units on the authorization.
- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: Banner Health Plans at bannerhealth.com/bhpprovider — pull the current ABA Prior Authorization Form and ask the plan directly; none of this is published at plan level. [8][7]
- **Session-note signature** _(ask the plan)_: Follows the AHCCCS rule — Banner publishes no distinct ABA clinical policy, only its own ABA Prior Authorization Form: 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. [8][7]
  - Ask the plan: Banner Health Plans at bannerhealth.com/bhpprovider — pull the current ABA Prior Authorization Form and ask the plan directly; none of this is published at plan level.

## What intake should collect for Banner-University Family Care

- **Diagnosis (any qualifying):** AMPM 320-S baseline — ASD or another diagnosis justified by medical necessity, with a BHP recommendation.
- **Current Banner ABA PA form:** Pull it from bannerhealth.com/bhpprovider before submitting — the specifics aren't published anywhere else.
- **Network status:** In network, 97151/97152 and 97153/97154 need no PA; out of network they do. Confirm you are contracted before booking the assessment as auth-free.
- **County + plan line:** ACC vs. ALTCS membership — Banner holds both, on different rules.

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

## Verification of benefits (VOB) data

How Banner-University Family Care ABA benefits route and read on an eligibility check. Data last updated 2026-10-15.

### EDI routing

- **Payer ID (pVerify):** 01013
- **Payer ID (Change Healthcare / Optum):** 66901 — Optum RTE 66901 = "Banner University Family Care" is the ELIGIBILITY (270/271) ID (verified). The CLAIMS payer ID appears as 09830 in clearinghouse directories but Banner's own submissions page could not be fetched (header-overflow) — treat claims 09830 as unverified-from-primary; confirm via bannerhealth.com/bhpprovider/resources/claims/submissions.
- **Supports 270/271 eligibility:** Yes
- **Real-time eligibility:** Yes
- **Behavioral health administrator:** none (integrated — Banner / UA Health Plans)
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | — | — | 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 | — | — | 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 | — | — | 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 | — | — | 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 | — | — | 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 | — | — | 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 | — | — | 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 | — | — | 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 | — | — | 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 | — | — | 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:** Banner publishes an ABA Prior Authorization Form (treatment PA exists) but no clinical policy, assessment-PA rule, or durations — pull the current form from bannerhealth.com/bhpprovider. 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 Banner-University Family Care. AHCCCS ACC/DDD plans are capitated, but ABA tracks the AHCCCS physician fee schedule (see arizona-ahcccs rates) as the public benchmark — Banner-University Family 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

- **Benefits by phone:** Yes
- **Provider services phone:** 800-582-8686 (TTY 711)
- **Hours:** Monday–Friday, 7:30 a.m.–5:00 p.m. (after hours route to an answering service)
- **Fax:** 866-465-8340 (Grievance & Appeals fax)

Questions to ask on a verification call:

- Does 97151/97152 require prior authorization for this member, since Banner hasn’t published a standing PA rule?
- What’s the current PA requirement and turnaround for 97153–97158, 0362T, and 0373T?
- Is there a unit or hour cap per day or week for ABA treatment codes?
- Is telehealth allowed for ABA, and does it require a specific POS or modifier?

### VOB data sources

- https://www.optum.com/ (accessed 2026-07-23)
- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (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.azahcccs.gov/Resources/Downloads/EDIchanges/AZ270_271_CG.pdf (accessed 2026-07-23)
- https://www.bannerhealth.com/bhpprovider/resources/bh/materials (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)
- https://www.bannerhealth.com/bhpprovider/about/contact (accessed 2026-07-23)
- https://www.bannerhealth.com/bhpprovider/-/media/files/project/bhpprovider/manuals-and-directories/manuals/prov-bufc-prov-manual_eff07092026_en.pdf (accessed 2026-10-14)

## Common questions

### Does Banner-University Family Care cover ABA?

Yes — as an AHCCCS ACC plan it covers Behavior Analysis Services under AMPM 320-S. 97155–97158 need PA on Banner’s ABA Prior Authorization Form (97153 and 97154 only out of network); the plan publishes no distinct clinical policy beyond the state baseline.

### Does Banner require PA for the ABA assessment?

Not for in-network providers. Banner’s 2026 manual lists 97151 and 97152 for prior authorization “Non-Par only,” so an out-of-network provider needs PA for the assessment.

### What does Banner pay for ABA?

Not published. Benchmark against the AHCCCS physician fee schedule (97153 at $17.91–$23.69 per 15-minute unit by credential tier); your contract is the source of truth.

### Can an out-of-state BCBA treat Banner-University Family Care members in Arizona, including by telehealth?

Arizona requires a license (A.R.S. § 32-2091.02) but lets an out-of-state provider deliver telehealth after registering under A.R.S. § 36-3606. AHCCCS defines a Behavior Analyst as one licensed under A.R.S. § 32-2091, so plan on an Arizona license for Medicaid work.

### Can Banner-University Family Care authorize ABA retroactively?

Only at its discretion for good cause: send the Retrospective Review Request Form with the claim, explaining why authorization was not obtained; decision within 30 days.

### What is Banner–University Family Care’s timely filing limit for AHCCCS ABA claims?

120 days from the date of service for contracted providers unless your contract says otherwise (six months for non-contracted providers), per Banner’s 2026 manual. Resubmissions must arrive within one year of the date of service, and secondary claims within 60 days of the primary payer’s remittance advice. A.R.S. § 36-2904(G) is the outer limit for every AHCCCS plan: six months to file, twelve to reach clean-claim status.

### How fast does Banner–University Family Care pay a clean ABA claim?

Banner’s manual commits to adjudicating clean, authorized claims within 45 days of receipt unless your contract says otherwise. AHCCCS requires 95% of clean claims within 30 days and 99% within 60, with interest on non-hospital clean claims paid after 45 days. No weekly cutoff or check-run day is published.

## Primary sources

1. [CMS — NCCI for Medicaid (methodologies required for Medicaid fee-for-service; optional for MCOs)](https://www.cms.gov/medicare/coding-billing/ncci-medicaid)
2. [CMS — Medicaid NCCI Edit Files (practitioner MUE table effective 10/1/2026)](https://www.cms.gov/medicare/coding-billing/ncci-medicaid/medicaid-ncci-edit-files)
3. [AHCCCS Telehealth Code Set (guidelines eff. 01/01/2026; code sheet eff. 06/01/2026)](https://www.azahcccs.gov/PlansProviders/Downloads/MedicalCodingResources/TelehealthCodeSet.xlsx)
4. [AMPM 320-I — Telehealth (AHCCCS)](https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/300/320-I.pdf)
5. [AHCCCS ACOM 203 — Claims Processing (eff. 10/01/22)](https://www.azahcccs.gov/Shared/Downloads/ACOM/PolicyFiles/200/203v2.pdf)
6. [Banner – University Family Care — 2026 Provider Manual (eff. 7/9/2026)](https://www.bannerhealth.com/bhpprovider/-/media/files/project/bhpprovider/manuals-and-directories/manuals/prov-bufc-prov-manual_eff07092026_en.pdf)
7. [Banner Health Plans — behavioral health materials and forms](https://www.bannerhealth.com/bhpprovider/resources/bh/materials)
8. [AMPM 320-S — Behavior Analysis Services (AHCCCS)](https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/300/320S.pdf)
9. [AHCCCS — Available Health Plans list](https://www.azahcccs.gov/Members/Downloads/Resources/ENGLISH_HealthPlanList.pdf)
10. [Mercy Care — Applied Behavior Analysis provider page](https://www.mercycareaz.org/providers/applied-behavior-analysis.html)
11. [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)
12. [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)
13. [A.R.S. § 32-2091.02 — a behavior analyst must be licensed](https://www.azleg.gov/ars/32/02091-02.htm)
14. [A.R.S. § 32-2091.12 — unlicensed practice is a class 2 misdemeanor](https://www.azleg.gov/ars/32/02091-12.htm)
15. [A.R.S. § 36-3606 — interstate telehealth services; registration of out-of-state providers](https://www.azleg.gov/ars/36/03606.htm)
16. [A.R.S. § 36-3601 — telehealth definitions (“health care provider” includes Title 32, ch. 19.1 licensees)](https://www.azleg.gov/ars/36/03601.htm)
17. [A.R.S. § 32-2091.14 — AHCCCS recognizes licensed behavior analysts as behavioral health professionals](https://www.azleg.gov/ars/32/02091-14.htm)
18. [eCFR — 42 CFR 438.602(b)(1): the state must screen and enroll all managed care network providers](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-H/section-438.602)
19. [A.R.S. § 36-2904 — AHCCCS contracts; claim submission time limits (subsection G)](https://www.azleg.gov/ars/36/02904.htm)
20. [AHCCCS FFS Provider Billing Manual, Chapter 4 — General Billing Rules (rev. 11/03/2025)](https://www.azahcccs.gov/PlansProviders/Downloads/FFSProviderManual/FFS_Chap04GeneralBillingRules.pdf)
21. [AHCCCS — Provider Claim Disputes](https://www.azahcccs.gov/PlansProviders/RatesAndBilling/ManagedCare/claimdisputes.html)
22. [AMPM 540 — Electronic Visit Verification (effective 08/06/26)](https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/500/540.pdf)
23. [AHCCCS — Electronic Visit Verification (What is EVV?, updated Oct. 22, 2025)](https://www.azahcccs.gov/AHCCCS/Initiatives/EVV/)
24. [Banner Plans & Networks — Provider newsletters and notifications (B-UFC)](https://www.bannerhealth.com/bhpprovider/news/newsletters)
25. [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)
26. [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)
27. [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)
28. [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)
29. [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 October 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.