---
title: Carolina Complete Health ABA coverage (Standard Plan).
url: "https://carelu.com/payers/carolina-complete-health"
markdown_url: "https://carelu.com/payers/carolina-complete-health.md"
state: NC (North Carolina)
payer: Carolina Complete Health
kind: Medicaid managed care plan (MCO)
parent_program: North Carolina Medicaid
description: "How Carolina Complete Health administers NC Medicaid RB-BHT (ABA) — explicit deference to Clinical Coverage Policy 8F, the ABA outpatient treatment request checklist, portal submission, and its statewide footprint since absorbing WellCare of North Carolina."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Carolina Complete Health ABA coverage (Standard Plan).

_Payer Guide · Carolina Complete Health · Last updated September 2026 · 3 primary sources_

> Explicit CCP 8F deference + an ABA treatment-request checklist; statewide since 4/1/2026 (absorbed WellCare NC).

Carolina Complete Health — the physician-led Centene joint venture — administers RB-BHT with the cleanest policy posture of the Standard Plans: its behavioral-health page states outright that clinical requirements are detailed in Policy 8F on the state's Medicaid website. The plan's own contribution is operational: an ABA Outpatient Treatment Request Checklist that structures submissions. As of April 1, 2026, WellCare of North Carolina merged into Carolina Complete Health, extending the plan from its prior regional footprint to statewide availability — see the WellCare of North Carolina guide for the merger detail and the transition path for existing WellCare members.

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 CCP 8F, before rendering any RB-BHT service including assessment [1][2]
- **Prior auth for treatment**: Required — submit with the ABA outpatient treatment request checklist via the provider portal [1]
- **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 (Centene JV, physician-led)
- **Clinical rules:** Explicit deference to CCP 8F
- **Prior auth:** Required per 8F; ABA treatment-request checklist published
- **Portal:** provider.carolinacompletehealth.com
- **Footprint:** Statewide as of 4/1/2026 — absorbed WellCare of North Carolina
- **Rates:** ≥100% of the NC Medicaid fee schedule (state floor)

## How CCH administers RB-BHT

Clinically, everything is CCP 8F: PA before rendering any RB-BHT service (assessment included), authorization cycles tiered by intensity (180 calendar days at ≤16 hrs/week, 90 days above), LQASP treatment-plan reviews. Requests go through the provider portal accompanied by the plan's ABA Outpatient Treatment Request Checklist — using it as your internal submission template removes back-and-forth. Behavioral health is integrated in-house (clinical training questions go to BH_training@centene.com), and provider services runs at (833) 552-3876, Monday–Saturday 7am–6pm. Carolina Complete Health became a statewide Standard Plan effective April 1, 2026, when WellCare of North Carolina merged into it — so eligibility should no longer be screened by county for this plan. Note also that Partners Health Management's Tailored Plan documentation cross-references CCH policies, reflecting shared Centene infrastructure. [1][2][3]

## Intake gates

The questions that decide whether a family can start with Carolina Complete Health, 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 — 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]
- **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**: 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]
- **Other insurance (who pays first)**: 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]

## Delivery and billing rules

Coverage decides whether Carolina Complete Health 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 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]
- **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 Carolina Complete Health

- **Member plan history:** Members transitioning from WellCare of North Carolina land here after the 4/1/2026 merger — confirm which card/ID the family currently holds.
- **ASD diagnosis + validated tool:** Per CCP 8F, with the MD/DO/LP service order.
- **Checklist items:** Build intake to pre-fill the plan's ABA treatment-request checklist.

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

## Verification of benefits (VOB) data

How Carolina Complete Health ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 002462
- **Payer ID (Availity):** 68069 — Confirmed via CCH's own Electronic Claim Submission Provider Guide: "CCH's preferred clearinghouse is Availity... Payer ID 68069." Claims-context confirmation; CCH uses the single 68069 code across transactions on the Availity connection.
- **Payer ID (Change Healthcare / Optum):** 68069
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** none — No BH carve-out administrator is named for RB-BHT in CCH's behavioral-health provider materials — inferred as none absent evidence of a separate administrator; confirm via provider services (833) 552-3876.
- **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) — explicit deference to CCP 8F; no CCH-authored code list | Required — per CCP 8F, before rendering any RB-BHT service; submit with CCH's ABA Outpatient Treatment Request Checklist | — | — | — | — |
| 97152 | Yes (97152) — explicit deference to CCP 8F; no CCH-authored code list | Required — per CCP 8F, before rendering any RB-BHT service; submit with CCH's ABA Outpatient Treatment Request Checklist | — | — | — | — |
| 97153 | Yes (97153) — explicit deference to CCP 8F; no CCH-authored code list | Required — per CCP 8F, before rendering any RB-BHT service; submit with CCH's ABA Outpatient Treatment Request Checklist | — | — | — | — |
| 97154 | Yes (97154) — explicit deference to CCP 8F; no CCH-authored code list | Required — per CCP 8F, before rendering any RB-BHT service; submit with CCH's ABA Outpatient Treatment Request Checklist | — | — | — | — |
| 97155 | Yes (97155) — explicit deference to CCP 8F; no CCH-authored code list | Required — per CCP 8F, before rendering any RB-BHT service; submit with CCH's ABA Outpatient Treatment Request Checklist | — | — | — | — |
| 97156 | Yes (97156) — explicit deference to CCP 8F; no CCH-authored code list | Required — per CCP 8F, before rendering any RB-BHT service; submit with CCH's ABA Outpatient Treatment Request Checklist | — | — | — | — |
| 97157 | Yes (97157) — explicit deference to CCP 8F; no CCH-authored code list | Required — per CCP 8F, before rendering any RB-BHT service; submit with CCH's ABA Outpatient Treatment Request Checklist | — | — | — | — |
| 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:** CCH's ABA Outpatient Treatment Request Checklist references an "8-10 hour" figure for assessment/reassessment as narrative market-standard guidance, NOT a codified unit cap — do not treat as a hard limit. CCH's own clinical-policies index points straight to state 8F rather than hosting an equivalent numbered clinical policy. Verify via: provider portal / (833) 552-3876.
- **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 Carolina-Complete-Health-specific published rate schedule was found, so these figures are the floor CCH 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:** 1-833-552-3876
- **Hours:** Monday–Saturday, 7 a.m.–6 p.m.
- **Portal:** [Carolina Complete Health Provider Portal](https://provider.carolinacompletehealth.com)

Questions to ask on a verification call:

- What is your Availity payer ID for real-time 270/271 eligibility checks?
- Is RB-BHT administered in-house, or through a behavioral-health carve-out administrator?
- What are the unit caps and cap periods for 97151-97157?
- What telehealth modifiers and place-of-service codes are approved for RB-BHT?
- Is the ABA cost share a copay or coinsurance, charged per-visit or per-day, and does it apply to the deductible?

### VOB data sources

- https://network.carolinacompletehealth.com/resources/behavioral-health.html (accessed 2026-07-23)
- https://network.carolinacompletehealth.com/merger.html (accessed 2026-07-23)
- https://network.carolinacompletehealth.com/content/dam/centene/carolinacompletehealth/pdfs/Electronic-Claim-Submission-Provider-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/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://network.carolinacompletehealth.com/content/dam/centene/carolinacompletehealth/pdfs/Applied%20Behavioral%20Analysis%20Outpatient%20Treatment%20Request%20Checklist%20-%20Provider%20Guide.pdf (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 Carolina Complete Health cover ABA therapy?

Yes — RB-BHT per NC Clinical Coverage Policy 8F, which the plan defers to explicitly. PA is required before any RB-BHT service, submitted through the provider portal with the plan's ABA treatment-request checklist.

### Is Carolina Complete Health available statewide?

Yes, as of April 1, 2026 — it absorbed WellCare of North Carolina and now operates statewide as a Standard Plan, rather than the smaller regional footprint it held before the merger.

## Primary sources

1. [Carolina Complete Health — behavioral health page (8F deference, checklist)](https://network.carolinacompletehealth.com/resources/behavioral-health.html)
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. [NC Medicaid — WellCare NC and Carolina Complete Health merge April 1, 2026 (Provider Playbook)](https://medicaid.ncdhhs.gov/providers/provider-playbook-medicaid-managed-care/trending-topics/wellcare-north-carolina-and-carolina-complete-health-merge-april-1-2026)
4. [Carolina Complete Health — Provider Manual 2026 (last updated 6/29/2026, state approved)](https://network.carolinacompletehealth.com/content/dam/centene/carolinacompletehealth/pdfs/CCHE_PRV15_Provider_Manual_2026.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. [Carolina Complete Health — Provider Billing Manual (last updated 7/14/2026)](https://network.carolinacompletehealth.com/content/dam/centene/carolinacompletehealth/pdfs/CCH-Current-Provider-Billing-Manual.pdf)
8. [NC Medicaid — Managed Care Billing Guidance to Health Plans v36 (9/4/2026), §3.27 TPL](https://medicaid.ncdhhs.gov/health-plan-billing-guide-version-36/download?attachment=)
9. [TRICARE — Using Other Health Insurance (updated 10/17/2025)](https://www.tricare.mil/Plans/OHI)
10. [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.