Healthy Blue 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.^[3]

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]

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]

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).^[3]

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 an assessment and treatment plan, valid one year. Healthy Blue adopts the state Clinical Coverage Policies wholesale and publishes no ABA-specific referral rule of its own; code-level requirements are confirmed in the plan’s Precertification Lookup Tool and requests go through Availity Essentials’ Interactive Care Reviewer.^[3][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.^[3]

Healthy Blue’s manual (Blue Cross NC) sets behavioral health turnarounds tighter than the federal floor: routine initial requests are decided "within two business days of receipt of all necessary information but no later than 7 days from the request for services", and routine concurrent (continuing) requests "within one business day of obtaining all necessary information but no later than 7 days from the request for services." Expedited decisions come "no later than 72 hours after receipt of the request for service", and requests marked expedited that do not meet the federal urgency standard are downgraded to standard. RB-BHT is on the PA list. The manual gives no reauthorization lead time; CCP 8F requires the reauth before the current authorization expires (every 180 days at ≤16 hrs/week, every 90 above).^[1][3]

Healthy Blue pays last: submit to the primary insurer first, then bill Healthy Blue the balance. It is the one NC plan that answers the secondary-PA question in writing: "Blue Cross NC does not require prior authorization (PA) when the member has OHI. However, a PA will be required if Healthy Blue becomes the primary payer for the service(s) rendered" — so if the commercial plan denies or exhausts ABA, get Healthy Blue’s PA before Healthy Blue becomes primary. Pay-and-chase (paid first, recovered later) is limited to prenatal care, preventive pediatric services "including Early and Periodic Screening, Diagnosis and Treatment (EPSDT) and well-baby screenings", and child-support cases; everything else is cost-avoided. Check other coverage in Availity, not NCTracks. Under federal rules TRICARE pays before Medicaid and CHAMPVA pays first when the child is also Medicaid-eligible.^[1][4][5]

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]

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]

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]

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]

Follows the NC Medicaid rule on covered settings (clinic, home, school, community, individually justified in the treatment plan). One plan-level note that matters for geography rather than the claim: the Healthy Blue provider manual exempts RB-BHT from the plan’s standard network time and distance standards.^[3][1]

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]