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.[7][8]
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 change, as reported in the news (azfamily, 3/5/2026): Mercy Care was reported to be ending its Action Behavior Centers and Centria contracts, and told the station it stands by its "decision to end contracts with certain providers." Displaced families are looking for in-network providers.[7][10]
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.[14][15][16][17][9][18][19]
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.[14][15][16][17][9][18][19]
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 Mercy Care’s network has to be enrolled with AHCCCS as well.[14][15][16][17][9][18][19]
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 Mercy 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.”[20][21][6][22][23][24]
Payment. 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. Other AHCCCS plans write shorter filing limits into their own manuals (Banner and AzCH use 120 days, UnitedHealthcare Community Plan 90), and Mercy Care’s own manual could not be retrieved at this review, so check your Mercy Care contract for its filing limit and payment terms.[20][21][6][22][23][24]
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 Mercy Care members the dispute is filed with Mercy Care. An unfavourable Notice of Decision can be taken to a state fair hearing within 30 days of receipt.[20][21][6][22][23][24]
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.[20][21][6][22][23][24]
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.[9][7]
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.[9][7]
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.[9][7]
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.[9][7]
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.[7][8][9]
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.[26][8][27][28]
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.[7][26][29][30][31]
Unless Mercy Care publishes something different (its provider pages return 403 to automated retrieval, so we could not check), 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.[5][4][9]
Blocked on: Mercy Care provider services / Availity — confirm Mercy Care follows the AHCCCS Telehealth Code Set (GT, originating-site POS) for 97151–97158 without extra authorization rules.
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.[9][7]
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)."[9][11][12][8]
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."[9][8]
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 no per-day ceiling (services are prescribed “in specific dosages, frequency, intensity, and duration” by the recommending BHP), and the AHCCCS Behavioral Health Services Matrix it points to lists provider types, places of service and modifiers with no unit column, so the authorization is the ceiling. CMS requires the Medicaid NCCI unit edits on fee-for-service claims but calls them “desirable but optional” for managed care plans; the public Medicaid MUE for 97153 is 32 units per claim line. Mercy Care’s own claim edits could not be read (mercycareaz.org returns 403 to automated retrieval).[9][1][2][3]
Blocked on: Mercy Care provider services / Availity — ask whether Medicaid MUEs apply to ABA claim lines; the authorization letter states the units per code.
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.[9][8]
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.[9][11][8]
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.
There is no public plan fee schedule. AHCCCS says its fixed ABA rates (effective November 1, 2023) apply only to fee-for-service programs and have “no impact on the contracts that AHCCCS health plans negotiate with their providers”: “MCOs and providers may negotiate any contracted rate that is agreed to by both parties.” Your rate is in your contract with Mercy Care; the AHCCCS fee-for-service schedule does not bind the plan.
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.
Six months from the date of service (or from the date eligibility is posted, if later), and twelve months to reach clean-claim status. A.R.S. § 36-2904(G) sets those limits for every AHCCCS contracted health plan, Mercy Care included; the plan’s payment terms are in its contract and provider manual.
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.
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