Alliance Health ABA coverage (NC Tailored Plan).

Follows the NC Medicaid rule: CCP 8F carries no upper age bound (the 8/1/2026 rewrite removed "under 21 years of age" from the eligibility provision), under-21 members carry the EPSDT special provision, and beneficiaries under three may start on a provisional diagnosis.^[3][1]

Follows the NC Medicaid rule: no expiry on the ASD diagnosis itself, but a provisional under-3 diagnosis must become non-provisional within six months, an adaptive behavior assessment must be under 3 years old, and diagnostic documentation must be verified and on file before services start.^[3][1]

Follows the NC Medicaid rule: a non-provisional ASD diagnosis comes from a Licensed Psychologist, a supervised Licensed Psychological Associate, or a physician (MD or DO); a Licensed School Psychologist evaluation may be used where the required testing is included; a provisional under-3 diagnosis may also come from a trained master’s-level licensed clinician within scope.^[3][1]

Alliance enforces the diagnostic-instrument bar more explicitly than any other NC plan: its February 2026 RB-BHT guidance names ADI-R, ADOS-2, CARS-2 and TELE-ASD-PEDS as acceptable and rejects GARS, M-CHAT and SRS as standalone diagnoses. Note the state rule it sits on has since been rewritten — the finalized CCP 8F (eff. 8/1/2026) names BOSA, Tele-ASD-Peds, ADOS-2 and CARS2-ST/CARS2-HF, and does not list ADI-R — so screen referral packets against both lists and confirm the current Alliance guidance version before relying on ADI-R alone.^[3][1][1]

Alliance is the strictest documented enforcer of the state service-order rule: signed by an MD, DO or licensed psychologist, based on a behavioral, adaptive or functional assessment, dated on or before the service start, valid one year — and a bare "medical necessity statement" does not qualify. Alliance’s fillable RB-BHT cover sheet accompanies each service request.^[3][1][1]

Follows the NC Medicaid rule (Attachment A, eff. 8/1/2026): GT telehealth is billable for 97151 with clinical justification and for 97155 up to 50% of total 97155 billing per beneficiary per 180 days; telehealth is removed entirely for 97152, 97153 and 97154; 97156 and 97157 remain telehealth eligible and are the only KX telephonic services, on a documented caregiver health or access barrier.^[3][1]

Alliance’s provider manual (V.26, March 2026) sets standard authorization decisions at 14 calendar days and expedited at "72 hours of the request", each extendable by 14 calendar days, with retrospective reviews at 30 calendar days; "All timelines in this document refer to calendar days unless otherwise specified," and "Incomplete forms are not processed and will be returned to the requesting provider." The federal managed-care ceiling for rating periods starting on or after January 1, 2026 is 7 calendar days standard, which reaches NC plans from July 1, 2026 — after this manual edition, so expect 7 and confirm with Alliance UM. Continuing requests are due "on or before the last day of the previously authorized date of service"; CCP 8F requires the RB-BHT reauth before the current authorization expires.^[4][5][6][3]

"Alliance Health is the payer of last resort. Providers are required to collect all third-party funds prior to submitting claims." Upload the other insurer’s RA/EOB into ACS with the claim (a $0-paid third-party claim needs the denial documentation), and "Only the remaining amount of the consumer responsibility under their insurance policy is reimbursable by Alliance Health when Medicaid is secondary coverage." If the other insurer pays later, send a replacement claim within 30 calendar days. Pay-and-chase: "EPSDT claims are paid by Medicaid as the primary payer; Alliance Health will seek recovery from any liable third party." State funds pay after Medicaid for state-funded services. The manual does not say whether its own prior authorization is still needed when it pays second; CCP 8F requires prior approval before rendering RB-BHT and carves out no exception for members with other insurance, so get the plan’s authorization on file unless the plan confirms in writing that it is waived. Under federal rules TRICARE pays before Medicaid and CHAMPVA pays first when the child is also Medicaid-eligible.^[4][3][7][8]

Follows the NC Medicaid rule: at least 10% of paraprofessional-delivered services must involve LQASP observation and direction, and above 200 paraprofessional hours per 180 days the LQASP-to-paraprofessional ratio must sit between 10% and 20%, documented in the treatment plan with deviations clinically justified. Incidental supervision is not billable.^[3][1]

Follows the NC Medicaid rule: 97153 or 97154 may be billed concurrently with 97155 when a paraprofessional delivers the direct service under an eligible provider’s observation, but a single rendering provider may not bill 97153/97154 and 97155 simultaneously. 97151, 97152, 97156 and 97157 allow no concurrent billing, and non-RB-BHT services may not be billed for the same clock time.^[3][1]

Follows the NC Medicaid rule: no per-day unit ceiling is published — the limits are per authorization period. Plans at or under 16 hours a week run 180-day initial and reauthorization cycles; plans above 16 hours a week run 90-day cycles. Within a 180-day period, 97155 telehealth is capped at 50% of 97155 billing and at least six caregiver training sessions are required. Educational-setting and IEP hours are excluded from the treatment-hour calculation.^[3][1]

Follows the NC Medicaid rule: the staff member who delivered the service signs the note with credentials (professional) or job title (paraprofessional), and an LQASP or C-QP is not required to countersign a note written by non-LQASP/C-QP staff. A full note is required per contact per date of service with the elements listed in 8F subsection 5.5.1, and the treatment plan is signed and dated by the LQASP and the consenting party before services begin.^[3][1]

Follows the NC Medicaid rule: clinic, home, school and community settings are all payable in any combination, individually justified and documented in the treatment plan, with the goal of advancing toward natural settings. IDEA-duplicative school services are excluded, and telehealth or telephonic claims carry the provider’s usual place-of-service code.^[3][1]

Follows the NC Medicaid rule: a professional CMS-1500/837P claim through the plan, with Attachment B fixing which provider type may render each code; behavior technicians must hold RBT or ABAT certification within 120 calendar days of hire or of the agency’s first Medicaid enrollment, and all LQASPs and C-QPs must enroll as in-state NC providers as of August 2, 2026.^[3][1]