---
title: Alliance Health ABA coverage (NC Tailored Plan).
url: "https://carelu.com/payers/alliance-health-north-carolina"
markdown_url: "https://carelu.com/payers/alliance-health-north-carolina.md"
state: NC (North Carolina)
payer: Alliance Health (NC Tailored Plan)
kind: Medicaid managed care plan (MCO)
parent_program: North Carolina Medicaid
description: "How Alliance Health administers NC Medicaid RB-BHT (ABA) — CCP 8F clinical rules, published fee-schedule rates, and the state's strictest documented enforcement on diagnostic instruments and service orders."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Alliance Health ABA coverage (NC Tailored Plan).

_Payer Guide · Alliance Health (NC) · Last updated September 2026 · 3 primary sources_

> Tailored Plan publishing real rates + the strictest diagnostic-tool and service-order enforcement.

Alliance Health is one of NC's four Tailored Plans, and for ABA providers it stands out on two fronts: it publishes an actual rate schedule (the clearest public confirmation of the state fee-schedule floor in action), and its February 2026 RB-BHT guidance enforces diagnostic-instrument and service-order requirements more explicitly than any other NC plan. Clinically it's straight CCP 8F — but its documentation bar is where referrals get screened out.

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

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — per 8F, with Alliance's RB-BHT cover sheet accompanying service requests [3][1]
- **Prior auth for treatment:** Not published / unverified. Verify via: Alliance Health's RB-BHT provider guidance, reissued for the 8/1/2026 CCP 8F. The flat ‘180-day cycles’ here is the pre-rewrite cadence; §5.1 is now tiered (up to 180 calendar days at ≤16 hrs/week, up to 90 above it). Confirm Alliance UM applies the tiering before quoting a reauth date to a family. [3]
- **Autism diagnosis required?**: Yes — ASD via ADI-R, ADOS-2, CARS-2, or TELE-ASD-PEDS; screeners alone rejected [1]

## At a glance

- **Plan type:** NC Tailored Plan (public LME/MCO)
- **Clinical rules:** CCP 8F + operational RB-BHT guidance (Feb 2026)
- **Prior auth:** Required per 8F, with Alliance's RB-BHT cover sheet
- **Diagnostic bar:** ADI-R, ADOS-2, CARS-2, TELE-ASD-PEDS accepted; GARS/M-CHAT/SRS insufficient alone
- **Service order:** MD/DO/LP-signed, assessment-based, valid 1 year, dated before start
- **Rates (per 15 min):** 97151 $30.56 · 97153 $20.81 · 97155 $32.22 · 97156 $23.70

## The documentation bar

Alliance's guidance names the acceptable ASD diagnostic instruments — ADI-R, ADOS-2, CARS-2, and TELE-ASD-PEDS — and explicitly rejects GARS, M-CHAT, and SRS as standalone diagnoses. It's equally specific on the service order: signed by an MD, DO, or licensed psychologist, based on a behavioral/adaptive/functional assessment, dated on or before the service start, valid one year — and a bare "medical necessity statement" does not qualify. Screen referral packets against both requirements at intake; sending families back for a qualifying diagnostic evaluation mid-authorization is where NC pipelines stall. [1]

## Rates & submission

Alliance publishes its standard rate schedule outright — RB-BHT at the state fee-schedule levels, per 15-minute unit, effective 10/1/2025: 97151 $30.56, 97152 $61.73, 97153 $20.81, 97154 $11.37, 97155 $32.22, 97156 $23.70, 97157 $11.51 (noted as subject to LME/MCO funding). Authorization follows the 8F baseline — PA on everything, with authorization length tiered by intensity (180 calendar days at ≤16 hrs/week, 90 above) — and with the plan's fillable RB-BHT cover sheet accompanying service requests through Alliance UM. Alliance also participates as a Children & Families Specialty Plan network partner. [2]

## Intake gates

The questions that decide whether a family can start with Alliance Health (NC Tailored Plan), and what they have to bring.

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

## Delivery and billing rules

Coverage decides whether Alliance Health (NC Tailored Plan) 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 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]
- **Concurrent billing (97153 + 97155)**: 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]
- **Daily limits / MUEs**: 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]
- **Session-note signature**: 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]
- **Place of service**: 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]
- **Bill as provider**: 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]

## What intake should collect for Alliance Health (NC Tailored Plan)

- **Diagnostic instrument check:** Confirm the diagnosis used ADI-R, ADOS-2, CARS-2, or TELE-ASD-PEDS — screeners alone will be rejected.
- **Qualifying service order:** MD/DO/LP-signed, assessment-based, dated on/before start, within 1 year.
- **RB-BHT cover sheet:** Include Alliance's fillable cover sheet with every service request.

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

## Verification of benefits (VOB) data

How Alliance Health (NC Tailored Plan) ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Behavioral health administrator:** none — Alliance is itself the LME/MCO administering behavioral health (including RB-BHT) directly — inferred from its role as a Tailored Plan, not from a document naming "no carve-out" explicitly.
- **ABA rides on:** behavioral health benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required — per CCP 8F, submitted with Alliance’s fillable RB-BHT cover sheet through Alliance UM | 180 days (initial + reauth, per CCP 8F auth cycle) | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | Yes — GT modifier for telehealth (audio-visual). Telephonic (KX) delivery is not permitted for this code per CCP 8F’s Attachment A code table. | GT (telehealth) |
| 97152 | Yes | Required — per CCP 8F, submitted with Alliance’s fillable RB-BHT cover sheet through Alliance UM | 180 days (initial + reauth, per CCP 8F auth cycle) | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | Yes — GT modifier for telehealth (audio-visual). Telephonic (KX) delivery is not permitted for this code per CCP 8F’s Attachment A code table. | GT (telehealth) |
| 97153 | Yes | Required — per CCP 8F, submitted with Alliance’s fillable RB-BHT cover sheet through Alliance UM | 180 days (initial + reauth, per CCP 8F auth cycle) | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | Yes — GT modifier for telehealth (audio-visual). Telephonic (KX) delivery is not permitted for this code per CCP 8F’s Attachment A code table. | GT (telehealth) |
| 97154 | Yes | Required — per CCP 8F, submitted with Alliance’s fillable RB-BHT cover sheet through Alliance UM | 180 days (initial + reauth, per CCP 8F auth cycle) | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | Yes — GT modifier for telehealth (audio-visual). Telephonic (KX) delivery is not permitted for this code per CCP 8F’s Attachment A code table. | GT (telehealth) |
| 97155 | Yes | Required — per CCP 8F, submitted with Alliance’s fillable RB-BHT cover sheet through Alliance UM | Inferred from Vaya’s statewide-pattern passthrough: routinely approved up to 1 hour per 10 hours of 97153/97154 (10%); above that, reviewed for medical necessity. Not confirmed as an Alliance-specific rule. per 180 days (initial + reauth, per CCP 8F auth cycle) | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | Yes — GT modifier for telehealth (audio-visual). Telephonic (KX) delivery is not permitted for this code per CCP 8F’s Attachment A code table. | GT (telehealth) |
| 97156 | Yes | Required — per CCP 8F, submitted with Alliance’s fillable RB-BHT cover sheet through Alliance UM | 180 days (initial + reauth, per CCP 8F auth cycle) | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | Yes — GT modifier for telehealth (audio-visual). Telephonic (audio-only, KX modifier) also allowed, but ONLY when the caregiver's physical/behavioral health status or an access barrier (transportation, technology) prevents in-person or telehealth participation (CCP 8F §3.1.2/3.2.5). | GT (telehealth), KX (telephonic, caregiver-barrier criteria only) |
| 97157 | Yes | Required — per CCP 8F, submitted with Alliance’s fillable RB-BHT cover sheet through Alliance UM | 180 days (initial + reauth, per CCP 8F auth cycle) | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | Yes — GT modifier for telehealth (audio-visual). Telephonic (audio-only, KX modifier) also allowed, but ONLY when the caregiver's physical/behavioral health status or an access barrier (transportation, technology) prevents in-person or telehealth participation (CCP 8F §3.1.2/3.2.5). | GT (telehealth), KX (telephonic, caregiver-barrier criteria only) |
| 97158 | No — 97158 is not part of NC Medicaid's CCP 8F billable RB-BHT code set (97151–97157 only) | N/A | N/A per N/A | — | N/A | — |
| 0362T | No — 0362T is not part of NC Medicaid's CCP 8F billable RB-BHT code set (97151–97157 only) | N/A | N/A per N/A | — | N/A | — |
| 0373T | No — 0373T is not part of NC Medicaid's CCP 8F billable RB-BHT code set (97151–97157 only) | N/A | N/A per N/A | — | N/A | — |

Code notes:

- **97151:** Diagnostic-instrument bar applies at this step: ADI-R, ADOS-2, CARS-2, or TELE-ASD-PEDS required (Alliance Feb-2026 guidance); GARS/M-CHAT/SRS rejected as standalone.
- **97158, 0362T, 0373T:** Confirmed absent from CCP 8F's own CPT code table (Attachment A), from Alliance's and Trillium's posted rate schedules, and from Vaya's authorization guidelines and rate schedule — checked directly, not assumed from the CPT list.

### Medicaid rates

Source: Alliance Health — Standard Rate Schedule Effective 2025-10-01.

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | $30.56 | 15min | — |
| 97152 | $61.73 | 15min | — |
| 97153 | $20.81 | 15min | — |
| 97154 | $11.37 | 15min | — |
| 97155 | $32.22 | 15min | — |
| 97156 | $23.70 | 15min | — |
| 97157 | $11.51 | 15min | — |
| 97158 | N/A | N/A — not part of NC’s CCP 8F billable code set | — |
| 0362T | N/A | N/A — not part of NC’s CCP 8F billable code set | — |
| 0373T | N/A | N/A — not part of NC’s CCP 8F billable code set | — |

### Contacts

- **Provider services phone:** 855-759-9700
- **Phone menu path:** Member and Recipient Services (800-510-9132) is member-facing only — use Provider Support (855-759-9700) for practice/provider calls.
- **Portal:** [Alliance Health Provider Portal](https://providerportal.alliancehealthplan.org/)

Questions to ask on a verification call:

- What is Alliance's payer ID (pVerify, Availity, or Change Healthcare) for 270/271 eligibility checks — none is confirmed on any national payer list?
- Does Alliance support real-time 270/271 eligibility checks, or is this batch-only?
- What are Alliance's per-code unit caps for 97151-97157, beyond the 180-day authorization-cycle ceiling?
- Is there a copay or coinsurance for RB-BHT, and if so is it per-visit or per-day?
- Since Alliance is the LME-MCO itself, what STC bucket or benefit detail does a 270/271 eligibility check actually return for RB-BHT?

### VOB data sources

- 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)
- https://www.nctracks.nc.gov/content/dam/jcr:b987d9f5-d230-4c81-b78b-05780eb0bbaf/270_271%20Health%20Care%20Eligibility%20Benefit%20Inquiry%20and%20Response%20(7).pdf (accessed 2026-07-23)
- https://medicaid.ncdhhs.gov/documents/files/8f-1/open (accessed 2026-07-23)
- https://www.alliancehealthplan.org/provider-updates/guidance-for-rb-bht-providers/ (accessed 2026-07-23)
- https://providers.vayahealth.com/wp-content/uploads/2025/05/RB_BHT_Guidance_20250522.pdf (accessed 2026-07-23)
- https://www.alliancehealthplan.org/document-library/97251 (accessed 2026-07-23)
- https://www.trilliumhealthresources.org/sites/default/files/docs/Billing-Codes-Rates/Trillium-Rate-Table-FY-26-27.pdf (accessed 2026-07-23)
- https://providers.vayahealth.com/wp-content/uploads/2025/09/Authorization_Guidelines_Medicaid_RB_BHT_ASD.pdf (accessed 2026-07-23)

## Common questions

### Does Alliance Health cover ABA therapy?

Yes — as a Tailored Plan, Alliance administers RB-BHT under CCP 8F, paying the state fee-schedule rates (97153 at $20.81/15-min, 97155 at $32.22/15-min, effective 10/1/2025).

### What diagnostic tools does Alliance accept for ABA?

ADI-R, ADOS-2, CARS-2, and TELE-ASD-PEDS. GARS, M-CHAT, and SRS are explicitly insufficient as standalone diagnoses — a common reason referral packets bounce.

### What makes a valid service order for Alliance?

Signed by an MD, DO, or licensed psychologist; based on a behavioral, adaptive, or functional assessment; dated on or before the service start date; valid one year. A bare medical-necessity statement doesn't qualify.

## Primary sources

1. [Alliance Health — Guidance for RB-BHT Providers (Feb 2026)](https://www.alliancehealthplan.org/provider-updates/guidance-for-rb-bht-providers/)
2. [Alliance Health — Standard Rate Schedule](https://www.alliancehealthplan.org/document-library/97251)
3. [NC Medicaid — Clinical Coverage Policy 8F](https://medicaid.ncdhhs.gov/8f-research-based-behavioral-health-treatment-rb-bht-autism-spectrum-disorder-asd/open)
4. [Alliance Health — Tailored Plan/PIHP Provider Manual (V.26, revised March 2026)](https://www.alliancehealthplan.org/document-library/79431/)
5. [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)
6. [NC Medicaid Standard Plan contract, Amendment 17(18) — "Rating Period" defined as July 1 to June 30](https://medicaid.ncdhhs.gov/contract-30-190029-dhb-prepaid-health-plan-services-amendment-1718/open)
7. [TRICARE — Using Other Health Insurance (updated 10/17/2025)](https://www.tricare.mil/Plans/OHI)
8. [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.