---
title: AmeriHealth Caritas North Carolina ABA coverage (Standard Plan).
url: "https://carelu.com/payers/amerihealth-caritas-north-carolina"
markdown_url: "https://carelu.com/payers/amerihealth-caritas-north-carolina.md"
state: NC (North Carolina)
payer: AmeriHealth Caritas North Carolina
kind: Medicaid managed care plan (MCO)
parent_program: North Carolina Medicaid
description: "How AmeriHealth Caritas administers NC Medicaid RB-BHT (ABA) — deference to Clinical Coverage Policy 8F, the PA Lookup Tool and NaviNet workflow, UM contacts, and why its documents are best pulled manually."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# AmeriHealth Caritas North Carolina ABA coverage (Standard Plan).

_Payer Guide · AmeriHealth Caritas (NC) · Last updated September 2026 · 3 primary sources_

> CCP 8F deference; NaviNet + PA Lookup Tool; thinnest public paper trail of the NC plans.

AmeriHealth Caritas North Carolina administers the RB-BHT benefit as a Standard Plan, mapping its coverage decisions to the state Clinical Coverage Policies — including 8F for ABA. Fair warning on sourcing: AmeriHealth's provider site is aggressively bot-protected, so this guide leans on the state baseline plus the plan's published contact points, and flags the two documents your team should pull manually from the portal.

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:** Not published / unverified. Verify via: AmeriHealth Caritas NC Behavioral Health Utilization Management Guide + the plan's PA Lookup Tool. CCP 8F puts PA on every RB-BHT service including the assessment, but AmeriHealth removed PA from 240+ codes on 1/1/2025 and does not publish whether 9715x was included; the site blocks automated retrieval, so pull both from NaviNet or via carelu.com/sources. [2]
- **Prior auth for treatment:** Not published / unverified. Verify via: AmeriHealth Caritas NC Behavioral Health Utilization Management Guide. NOTE: the ‘180-day cycles’ in this value predates the 8/1/2026 CCP 8F rewrite — §5.1 is now tiered (up to 180 calendar days at ≤16 hrs/week, up to 90 above it). Confirm the plan restates the tiering before relying on the flat 180-day figure. [2]
- **Autism diagnosis required?**: Yes — ASD via a validated diagnostic tool; under-3s may start on a provisional diagnosis [2]

## At a glance

- **Plan type:** NC Medicaid Standard Plan
- **Clinical rules:** CCP 8F via the plan's Clinical Coverage Policy Reference Tool
- **Prior auth:** Required per 8F; confirm codes in the PA Lookup Tool
- **UM contact:** (888) 738-0004
- **Portal:** NaviNet + PA Lookup Tool at amerihealthcaritasnc.com
- **Rates:** ≥100% of the NC Medicaid fee schedule (state floor)

## How AmeriHealth administers RB-BHT

The clinical rules are the CCP 8F baseline: PA on all RB-BHT services including the assessment, authorization cycles tiered by intensity (180 calendar days at ≤16 hrs/week, 90 days above), LQASP treatment-plan reviews at least every six months. AmeriHealth's own layer is a Clinical Coverage Policy Reference Tool mapping to the state policies, a Behavioral Health Utilization Management Guide (January 2025 edition), and a PA Lookup Tool for code-level checks. One thing to verify directly: AmeriHealth eliminated prior authorization on 240+ physical and behavioral-health codes effective January 1, 2025 — whether any 9715x codes made that list isn't publicly confirmed, so run your codes through the Lookup Tool rather than assuming. [2][3]

Because the plan's site blocks automated access, have your team download the current BH UM Guide and the PA Lookup results from the portal directly, and keep dated copies with your payer files. [2][3]

## Intake gates

The questions that decide whether a family can start with AmeriHealth Caritas North Carolina, 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. [2]
- **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. [2]
- **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. [2]
- **Diagnostic tools required**: 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]
- **Referral required?**: 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]
- **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. [2]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: 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]

## Delivery and billing rules

Coverage decides whether AmeriHealth Caritas North Carolina 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. [2]
- **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. [2]
- **Daily limits / MUEs**: 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]
- **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. [2]
- **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. [2]
- **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. [2]

## What intake should collect for AmeriHealth Caritas North Carolina

- **Member ID + plan confirmation:** Standard AmeriHealth Caritas NC vs. other channels — verify at (888) 738-0004 if in doubt.
- **ASD diagnosis + validated tool:** Per CCP 8F, with the MD/DO/LP service order.
- **Code-level PA check:** Run the planned CPT codes through the PA Lookup Tool before promising timelines.

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

## Verification of benefits (VOB) data

How AmeriHealth Caritas North Carolina ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (Change Healthcare / Optum):** 14337 — 14337 is Optum's Real-Time Eligibility code; the plan's own provider guide and Optum's Institutional/Professional Claims lists instead show 81671 for CLAIMS — a different code from the RTE entry used here for 270/271.
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** none — No BH carve-out administrator is named anywhere in AmeriHealth's UM Guide for RB-BHT — inferred as none absent evidence of a separate administrator; confirm via AmeriHealth UM at (888) 738-0004.
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes (97151) — per CCP 8F deference; confirmed in AmeriHealth's own UM Guide, which cites "8F. (ncdhhs.gov)" rather than restating anything | Required — per CCP 8F. AmeriHealth eliminated PA on 240+ physical/BH codes effective 1/1/2025; whether any 9715x code is among them is not stated on the PA Lookup Tool's public page and requires an interactive per-code query. | — | — | — | — |
| 97152 | Yes (97152) — per CCP 8F deference; confirmed in AmeriHealth's own UM Guide, which cites "8F. (ncdhhs.gov)" rather than restating anything | Required — per CCP 8F. AmeriHealth eliminated PA on 240+ physical/BH codes effective 1/1/2025; whether any 9715x code is among them is not stated on the PA Lookup Tool's public page and requires an interactive per-code query. | — | — | — | — |
| 97153 | Yes (97153) — per CCP 8F deference; confirmed in AmeriHealth's own UM Guide, which cites "8F. (ncdhhs.gov)" rather than restating anything | Required — per CCP 8F. AmeriHealth eliminated PA on 240+ physical/BH codes effective 1/1/2025; whether any 9715x code is among them is not stated on the PA Lookup Tool's public page and requires an interactive per-code query. | — | — | — | — |
| 97154 | Yes (97154) — per CCP 8F deference; confirmed in AmeriHealth's own UM Guide, which cites "8F. (ncdhhs.gov)" rather than restating anything | Required — per CCP 8F. AmeriHealth eliminated PA on 240+ physical/BH codes effective 1/1/2025; whether any 9715x code is among them is not stated on the PA Lookup Tool's public page and requires an interactive per-code query. | — | — | — | — |
| 97155 | Yes (97155) — per CCP 8F deference; confirmed in AmeriHealth's own UM Guide, which cites "8F. (ncdhhs.gov)" rather than restating anything | Required — per CCP 8F. AmeriHealth eliminated PA on 240+ physical/BH codes effective 1/1/2025; whether any 9715x code is among them is not stated on the PA Lookup Tool's public page and requires an interactive per-code query. | — | — | — | — |
| 97156 | Yes (97156) — per CCP 8F deference; confirmed in AmeriHealth's own UM Guide, which cites "8F. (ncdhhs.gov)" rather than restating anything | Required — per CCP 8F. AmeriHealth eliminated PA on 240+ physical/BH codes effective 1/1/2025; whether any 9715x code is among them is not stated on the PA Lookup Tool's public page and requires an interactive per-code query. | — | — | — | — |
| 97157 | Yes (97157) — per CCP 8F deference; confirmed in AmeriHealth's own UM Guide, which cites "8F. (ncdhhs.gov)" rather than restating anything | Required — per CCP 8F. AmeriHealth eliminated PA on 240+ physical/BH codes effective 1/1/2025; whether any 9715x code is among them is not stated on the PA Lookup Tool's public page and requires an interactive per-code query. | — | — | — | — |
| 97158 | No — 97158 is not in CCP 8F Attachment A's billing-code table (97151-97157 only) or the restored NC Medicaid RB-BHT fee schedule | N/A — code not covered under NC Medicaid RB-BHT | N/A per N/A | — | N/A | — |
| 0362T | No — 0362T is not in CCP 8F Attachment A's billing-code table (97151-97157 only) or the restored NC Medicaid RB-BHT fee schedule | N/A — code not covered under NC Medicaid RB-BHT | N/A per N/A | — | N/A | — |
| 0373T | No — 0373T is not in CCP 8F Attachment A's billing-code table (97151-97157 only) or the restored NC Medicaid RB-BHT fee schedule | N/A — code not covered under NC Medicaid RB-BHT | N/A per N/A | — | N/A | — |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157:** Verify via: AmeriHealth Caritas NC Prior Authorization Lookup Tool (interactive, code-by-code) and UM at (888) 738-0004.
- **97158, 0362T, 0373T:** Confirmed absent from both the current, finalized CCP 8F (Amended Date: August 1, 2026, rewritten and published this cycle) and the fee schedule restored 2026-01-05 — NC Medicaid's RB-BHT code set does not include this code, unlike some other states' ABA fee schedules. Unchanged by the 8/1/2026 rewrite.

### Medicaid rates

Source: NC Medicaid RB-BHT fee schedule — the mandatory reimbursement floor Standard Plans must meet. No AmeriHealth-Caritas-specific published rate schedule was found, so these figures are the floor AmeriHealth must meet, not a plan-confirmed paid rate. 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 | — |

### Contacts

- **Provider services phone:** 1-833-900-2262
- **Phone menu path:** BH UM direct line 1-833-900-2262 handles RB-BHT prior-authorization questions during business hours; after hours, weekends, and holidays route to Member Services at 1-855-375-8811. Fax the completed Prior Authorization Request Form to 1-833-893-2262 (Inpatient Concurrent Review uses a separate fax, 1-833-894-2262).
- **Hours:** Monday–Friday, 8 a.m.–5 p.m. (Behavioral Health Utilization Management)
- **Portal:** [NaviNet](https://www.amerihealthcaritasnc.com/provider/resources/navinet.aspx)
- **Fax:** 1-833-893-2262

Questions to ask on a verification call:

- Which payer ID do you use for 270/271 real-time eligibility checks (pVerify, Availity, and Change Healthcare all show gaps or unreconciled codes)?
- Is ABA/RB-BHT administered in-house, or through a separate behavioral-health carve-out administrator?
- What are the current unit caps and cap periods for 97151-97157?
- What telehealth modifiers and place-of-service codes are approved for RB-BHT?
- Is the RB-BHT cost share a copay or coinsurance, charged per-visit or per-day, and does the deductible apply?

### VOB data sources

- https://www.amerihealthcaritasnc.com/assets/pdf/provider/resources/utilization-management-guide.pdf (accessed 2026-07-23)
- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://business.optum.com/content/dam/optum4/business/open_source/practice-management/real-time-eligibility-payer-list.pdf (accessed 2026-07-23)
- https://www.optum.com/content/dam/optum4/business/open_source/practice-management/institutional-claims-payer-list.pdf (accessed 2026-07-23)
- https://www.optum.com/content/dam/optum4/business/open_source/practice-management/professional-claims-payer-list.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://www.amerihealthcaritasnc.com/provider/resources/prior-authorization-lookup (accessed 2026-07-23)
- https://medicaid.ncdhhs.gov/8f-research-based-behavioral-health-treatment-rb-bht-autism-spectrum-disorder-asd/open (accessed 2026-09-01)
- https://medicaid.ncdhhs.gov/blog/2025/12/19/medicaid-rate-reduction-reversal-update (accessed 2026-07-23)
- https://www.alliancehealthplan.org/document-library/97251 (accessed 2026-07-23)

## Common questions

### Does AmeriHealth Caritas NC cover ABA therapy?

Yes — as a Standard Plan it administers NC Medicaid's RB-BHT benefit under Clinical Coverage Policy 8F, with prior authorization per the state baseline. Confirm code-level rules in the plan's PA Lookup Tool.

### How do I reach AmeriHealth Caritas NC utilization management?

UM runs at (888) 738-0004; the provider workflow uses NaviNet and the PA Lookup Tool at amerihealthcaritasnc.com. The January 2025 Behavioral Health UM Guide has the current details — pull it from the portal.

## Primary sources

1. [AmeriHealth Caritas NC — prior authorization resources (bot-blocked; access via portal)](https://www.amerihealthcaritasnc.com/provider/resources/physical-prior-auth)
2. [NC Medicaid — Clinical Coverage Policy 8F](https://medicaid.ncdhhs.gov/8f-research-based-behavioral-health-treatment-rb-bht-autism-spectrum-disorder-asd/open)
3. [AmeriHealth Caritas NC — Behavioral Health UM Guide (pull manually; bot-blocked)](https://www.amerihealthcaritasnc.com/content/dam/amerihealth-caritas/acnc/pdf/provider/resources/utilization-management-guide.pdf.coredownload.inline.pdf)
4. [AmeriHealth Caritas NC — Provider Manual (Version 16, published 10/2/2025)](https://www.amerihealthcaritasnc.com/assets/pdf/provider/provider-manual.pdf)
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.