AmeriHealth Caritas North Carolina ABA coverage (Standard 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.^[2]

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.^[2]

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.^[2]

Follows the NC Medicaid rule: the ASD diagnosis must use BOSA, Tele-ASD-Peds, ADOS-2, or CARS2-ST/CARS2-HF; screeners, educational determinations and informal impressions cannot start services. The packet also needs a skills assessment (VB-MAPP, ABLLS-R or ESDM Curriculum Checklist), an FBA where challenging behaviors are targeted, and an adaptive behavior assessment within 3 years (VABS-3, ABAS-3 or DP-4).^[2]

Follows the NC Medicaid rule: a service order signed and dated by a Licensed MD, DO or Licensed Psychologist, in place on or before the first date of service, based on a behavioral/adaptive/functional assessment and treatment plan, valid one year and re-ordered annually. 97151 and 97152 need no service order for prior approval; 97153–97157 do.^[2]

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.^[2]

AmeriHealth Caritas’ manual (Version 16, October 2025) says standard decisions come "no later than 14 calendar days after AmeriHealth Caritas North Carolina receives the request", extendable up to 14 more calendar days, and expedited decisions "no later than 72 hours after receipt of the request for service" (also extendable up to 14 calendar days); its BH UM Guide lists 14 calendar days as the expected determination time for RB-BHT under 8F. A missed deadline counts as an adverse benefit determination the family can appeal. 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 — newer than this manual edition, so expect 7 and confirm with ACNC UM. No reauthorization lead time is published; CCP 8F requires the reauth before the current authorization expires.^{[4][3][5][6][2]}

ACNC pays last: "health care providers are required to bill the Primary Insurer first and obtain an Explanation of Benefits (EOB) or Claim Adjustment Reason Codes (CARC)" and claims carrying the primary EOB must reach ACNC "within 180 days of the date on the primary insurer's EOB." ACNC "will pay and then chase" for EPSDT, "Diagnostic and Treatment (Medical Necessity) after Early and Periodic Screening", and child support enforcement. 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][2][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.^[2]

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.^[2]

Follows the NC Medicaid rule: no per-day unit ceiling; limits are per authorization period (180-day cycles at or under 16 hours a week, 90-day cycles above it), with the 50% 97155 telehealth cap and the six-caregiver-training minimum per 180 days. AmeriHealth publishes no plan-specific ABA unit table; because the plan removed prior authorization from 240+ codes effective January 1, 2025 without publicly confirming whether any 9715x codes were included, run the planned codes through the plan’s PA Lookup Tool rather than assuming.^[2][3]

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.^[2]

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.^[2]

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.^[2]