On October 1, 2019, a provider notification was sent notifying providers of a change regarding
Prior Authorization for Applied Behavioral Analysis (ABA) CPT Codes
. As a result of that notification, several questions have come to our attention from providers that we would like to help clarify. We have put together a listing of Frequently Asked Questions (FAQs) to assist.
Applied Behavior Analysis (ABA) FAQ’s
What is Applied Behavior Analysis (ABA)?
ABA is considered an evidence- based best practice treatment by the US Surgeon General and by the American Psychological Association. ABA involves many techniques for understanding and changing behavior. The goal of any ABA program is to help each person work on skills that will help them become more independent and successful in the short term as well as the future. A Board Certified Behavior Analyst will start by doing a detailed assessment of each person’s skills and preferences. They will use this to write specific treatment goals.
Clinical and medical necessity will continue to be an essential part of coordinating care and will remain as the primary function of the Child and Family Team (CFT) and Adult Recovery Team (ART).
Does Mercy Care cover ABA services?
Yes, Applied Behavior Analysis is one type of treatment that Mercy Care contracted providers offer. Services are referred by the Child and Family Team (CFT) or Adult Recovery Team (ART). Visit our website -
https://www.mercycareaz.org/
to learn more about ABA services and those that provide this level of treatment.
Does Mercy Care require providers providing ABA services to use the new CPT Adaptive Behavior
and Treatment codes 97153-97158, 0362T and 0373T ?
Yes,
starting October 1, 2019, Mercy Care expects providers to utilize the CPT Codes 97153-97158, 0362T and 0373Twhen providing Adaptive Behavior Assessment and Treatment.
For more descriptions on the codes, please use the following resources:
Is the prior authorization for ABA only applicable when Mercy care is Primary or is it for secondary as well?
Yes, prior authorization is required when Mercy Care is the primary payor for services. If the member has other primary insurance there is no authorization required. However, If the primary insurance does not cover the service or the member has exhausted their benefit authorization will be required. Please note this on the authorization request form.
When serving a family who has private insurance, how are co-pays and deductibles paid?
AHCCCS will pay deductibles and copays for providers who are registered with AHCCCS and providing AHCCCS covered services; this does not require a contract with AHCCCS. However, by registering, the provider agrees to not balance bill the insured. If the contract between the contractor and the provider does not state otherwise, a contractor shall pay the lesser of the difference between:
- The Primary Insurance Paid Amount and the Primary Insurance rate, i.e., the member’s copayment required under the Primary Insurance, OR
- The Primary Insurance Paid amount and the Contractor’s Contracted Rate
How do I submit claims and get reimbursed for the ABA service delivery provided to the member?
As a provider, I know the services I am providing are non-covered by the members primary insurance; however, the services appear to be covered by Medicaid. Do I have to bill the primary insurance each time for a denial prior to billing Medicaid?
The answer to this question depends on the services being provided. Mercy Care is aware that many behavioral health services are considered non-covered by Medicare and primary insurance plans. Services that begin with alpha characters H, and T are part of our internal by-pass system where we will consider the services as primary and do not expect the provider to bill the primary insurance for a denial. Examples include but are not limited to: H0004 (Behavioral Health Counseling), and T1016 (case management). If the member has primary coverage, Mercy Care will override editing related to coordination of benefits and pay the services as primary when no primary explanation of benefits is attached to the claim. If the services are considered covered by the members primary plan the provider is expected to bill the primary first so that the Medicaid plan can apply cost share. For remaining services being provided that do not begin with an H, S, or T HCPCS Code, the provider is expected to bill the primary first.
What codes require a Prior Authorization for ABA?
Effective November 1, 2019, a prior authorization is required for Adaptive Behavior
Treatment
(CPT Codes 97153-97158). Adaptive Behavior
Assessments
(CPT Codes 97151 and 97152) will not require authorization. Service(s) rendered without authorization may be denied for payment. Please note those members who are transitioning to Mercy Care DD effective October 1, 2019 as part of the DDD contract implementation will not require authorization for 180 days post transition.
What is the standard timeframe of Prior Authorization approval?
Mercy Care will authorize services for 60 days at a time.
Will Mercy Care require a specific ABA prior authorization form to be used, and will clinical documentation be requested during review?
Currently Mercy Care is not using a specific ABA form nor requesting additional documentation to be submitted at this time. Mercy Care will utilize the AHCCCS ABA Policy as a guide to determine criteria and will communicate changes related to ABA PA via Provider Notice for
Treatments
(CPT Codes 97153-97158). Adaptive Behavior
Assessments
(CPT Codes 97151 and 97152) will not require authorization. Service(s) rendered without authorization may be denied for payment. Please note those members who are transitioning to Mercy Care DD effective October 1, 2019 as part of the DDD contract implementation will not require authorization for 180 days post transition.
Thanks for all you do!
