Carolina Complete Health 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 — an MD/DO/Licensed Psychologist service order, dated on or before the first service, assessment-based, valid one year. Carolina Complete Health states outright that the clinical requirements are detailed in Policy 8F on the state Medicaid website; its own layer is the ABA Outpatient Treatment Request Checklist that structures portal submissions.^[2][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.^[2]

CCH’s 2026 manual (merged with WellCare NC on April 1, 2026) says standard decisions "will be made within fourteen (14) calendar days" and urgent/expedited ones "within seventy-two (72) hours of the receipt of the request"; concurrent reviews are decided within 72 hours of receiving the necessary information. It states the change as "Effective January 1, 2027": standard requests "within 7 calendar days, with a possible extension up to 14 calendar days." That date conflicts with the federal rule, which caps standard decisions at 7 calendar days for rating periods starting on or after January 1, 2026, and NC’s rating period starts July 1, so the ceiling reaches NC plans from July 1, 2026 — confirm with CCH UM which clock it is running. Lead time: the manual asks for standard requests "at least fourteen (14) business days prior" to the service (another passage says 14 calendar days); CCP 8F requires the RB-BHT reauth before the current authorization expires.^[4][5][6][2]

CCH is payer of last resort: bill the other insurer first and upload its EOB/EOP or rejection letter — without it "the claim will pend and/or deny until this information is received." Secondary claims are due within 365 calendar days of "the primary insurer's Explanation of Benefits/Remittance Advice date (whether the claim was paid or denied)." Check other coverage in CCH’s portal. Neither the provider nor the billing manual lists pay-and-chase services; the state’s plan billing guidance requires plans to pay and chase EPSDT and claims under a PA "approved as EPSDT medical necessity." 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][7][8][2][9][10]}

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 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.^[2]

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]