---
title: Healthy Blue North Carolina ABA coverage (Standard Plan).
url: "https://carelu.com/payers/healthy-blue-north-carolina"
markdown_url: "https://carelu.com/payers/healthy-blue-north-carolina.md"
state: NC (North Carolina)
payer: Healthy Blue (NC)
kind: Medicaid managed care plan (MCO)
parent_program: North Carolina Medicaid
description: "How Healthy Blue administers NC Medicaid RB-BHT (ABA) — full adoption of Clinical Coverage Policy 8F, Availity/Interactive Care Reviewer submission, behavioral-health fax lines, and the Children & Families Specialty Plan distinction."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Healthy Blue North Carolina ABA coverage (Standard Plan).

_Payer Guide · Healthy Blue (NC) · Last updated September 2026 · 3 primary sources_

> Straight CCP 8F via Availity/ICR; RB-BHT exempt from network distance rules; CFSP sibling plan.

Healthy Blue — the Anthem/Elevance Standard Plan — administers NC Medicaid's RB-BHT benefit by adopting the state Clinical Coverage Policies wholesale: no Healthy-Blue-specific ABA clinical criteria exist. That makes this a mechanics guide: where requests go, which fax lines answer, and one structural wrinkle — Blue Cross NC also operates the separate Children & Families Specialty Plan, so foster-care-involved children will show up under a different plan than standard Healthy Blue.

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 (all RB-BHT services PA'd); submit via Availity Interactive Care Reviewer [3][1]
- **Prior auth for treatment**: Required — tiered auth cycles per 8F: up to 180 calendar days at ≤16 hrs/week, up to 90 calendar days at >16 hrs/week [3]
- **Autism diagnosis required?**: Yes — ASD via a validated diagnostic tool; under-3s may start on a provisional diagnosis [3]

## At a glance

- **Plan type:** NC Medicaid Standard Plan (Anthem / Elevance)
- **Clinical rules:** CCP 8F adopted as-is — no plan-specific ABA policy
- **Prior auth:** Required per 8F; PA form + Precert Lookup Tool published
- **Submission:** Availity Essentials / Interactive Care Reviewer
- **Network note:** RB-BHT exempt from standard time/distance network rules
- **Rates:** ≥100% of the NC Medicaid fee schedule (state floor)

## How Healthy Blue administers RB-BHT

The provider manual lists RB-BHT among covered behavioral-health services and adopts NC's Clinical Coverage Policies — so the whole clinical picture (PA on everything including assessment, the tiered 180/90-day authorization cadence, LQASP plan reviews) is the CCP 8F baseline covered in the state guide. Submissions run through Availity Essentials' Interactive Care Reviewer; behavioral-health authorization fax lines are (844) 429-9636 for outpatient and (844) 439-3574 for inpatient, with provider services at (844) 594-5072. Use the plan's Precertification Lookup Tool to confirm code-level requirements before submitting. [1][3]

One provider-friendly detail from the manual: RB-BHT is explicitly exempt from the plan's standard network time/distance standards — an open-network posture that matters if you're expanding into new counties. [1][3]

## The Children & Families Specialty Plan wrinkle

Since December 1, 2025, child-welfare-involved members are auto-enrolled in the statewide Children & Families Specialty Plan ("Healthy Blue Care Together"), also operated by Blue Cross NC — a separate plan from standard Healthy Blue with its own member IDs. For intake, this means a foster or kinship placement family saying "we have Healthy Blue" needs one more verification question before you pick the submission path.

## Intake gates

The questions that decide whether a family can start with Healthy Blue (NC), 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. [3]
- **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. [3]
- **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. [3]
- **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). [3]
- **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 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]
- **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. [3]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: 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]

## Delivery and billing rules

Coverage decides whether Healthy Blue (NC) 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. [3]
- **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. [3]
- **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. [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. [3]
- **Place of service**: 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]
- **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. [3]

## What intake should collect for Healthy Blue (NC)

- **Standard Healthy Blue vs. Care Together (CFSP):** Child-welfare-involved members are on the specialty plan — confirm which ID the family holds.
- **ASD diagnosis + validated tool:** Per CCP 8F, with the MD/DO/LP service order.
- **County / region:** RB-BHT's network-rules exemption makes cross-county serving feasible — capture location anyway for scheduling.

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

## Verification of benefits (VOB) data

How Healthy Blue (NC) ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00700 — Confirmed this pass: pVerify's March 2026 payer list carries "00700 HEALTHY BLUE NORTH CAROLINA" with Eligibility=Yes — 00700 is pVerify's own eligibility code, distinct by design from Availity's 00602 and Optum's RTE code 14422 (each clearinghouse assigns its own payer ID for this plan).
- **Payer ID (Availity):** 00602
- **Payer ID (Change Healthcare / Optum):** 14422 — Optum's Professional Claims list shows 00602 (matching Availity/the plan's own provider manual), but its separate Real-Time Eligibility list shows a DIFFERENT code, 14422, for the same payer — use 14422 for 270/271 eligibility checks, 00602 for claims.
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** none — No BH carve-out administrator is named anywhere in the Healthy Blue NC Provider Manual for RB-BHT — inferred as none (billed as a standard Medicaid medical benefit) absent evidence of a separate administrator; confirm via Healthy Blue provider services.
- **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; Healthy Blue publishes no ABA-specific code list of its own | Required — per CCP 8F; check the Availity Interactive Care Reviewer / Precertification Lookup Tool for the current code-specific PA flag (no ABA-specific static list was found) | — | — | — | — |
| 97152 | Yes (97152) — per CCP 8F deference; Healthy Blue publishes no ABA-specific code list of its own | Required — per CCP 8F; check the Availity Interactive Care Reviewer / Precertification Lookup Tool for the current code-specific PA flag (no ABA-specific static list was found) | — | — | — | — |
| 97153 | Yes (97153) — per CCP 8F deference; Healthy Blue publishes no ABA-specific code list of its own | Required — per CCP 8F; check the Availity Interactive Care Reviewer / Precertification Lookup Tool for the current code-specific PA flag (no ABA-specific static list was found) | — | — | — | — |
| 97154 | Yes (97154) — per CCP 8F deference; Healthy Blue publishes no ABA-specific code list of its own | Required — per CCP 8F; check the Availity Interactive Care Reviewer / Precertification Lookup Tool for the current code-specific PA flag (no ABA-specific static list was found) | — | — | — | — |
| 97155 | Yes (97155) — per CCP 8F deference; Healthy Blue publishes no ABA-specific code list of its own | Required — per CCP 8F; check the Availity Interactive Care Reviewer / Precertification Lookup Tool for the current code-specific PA flag (no ABA-specific static list was found) | — | — | — | — |
| 97156 | Yes (97156) — per CCP 8F deference; Healthy Blue publishes no ABA-specific code list of its own | Required — per CCP 8F; check the Availity Interactive Care Reviewer / Precertification Lookup Tool for the current code-specific PA flag (no ABA-specific static list was found) | — | — | — | — |
| 97157 | Yes (97157) — per CCP 8F deference; Healthy Blue publishes no ABA-specific code list of its own | Required — per CCP 8F; check the Availity Interactive Care Reviewer / Precertification Lookup Tool for the current code-specific PA flag (no ABA-specific static list was found) | — | — | — | — |
| 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: Availity Essentials Interactive Care Reviewer / Precertification Lookup Tool. The Healthy Blue NC Provider Manual's only ABA reference is a single care-management sentence — no CPT codes, unit caps, POS codes, or modifiers appear anywhere in it.
- **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 (>=100% of the state schedule unless the provider agrees otherwise). No Healthy-Blue-specific published rate schedule was found, so these figures are the floor Healthy Blue 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:** 844-594-5072
- **Phone menu path:** Provider Services main line, option 2 for Prior Authorization/Notification – Physical Health. Outpatient and Inpatient Behavioral Health Utilization Management (where RB-BHT authorization sits) is reached directly at 844-594-5082 — no separate IVR menu is documented for BH UM in the Provider Manual.
- **Hours:** Monday–Saturday, 7 a.m.–6 p.m. Eastern time (voice portal accessible 24/7)
- **Portal:** [Availity Essentials / Healthy Blue Provider Portal](https://provider.healthybluenc.com)

Questions to ask on a verification call:

- Do you use payer ID 00602 or 14422 for real-time 270/271 eligibility checks (the plan's Professional Claims and Real-Time Eligibility lists show different codes)?
- Does Healthy Blue administer RB-BHT in-house, or is there a behavioral-health carve-out administrator I should route to instead?
- What are the unit caps and cap periods for 97151-97157?
- What place-of-service codes and telehealth modifiers (GT/CR) are approved for RB-BHT billing?
- Is the ABA cost share a copay or coinsurance, and is it charged per-visit or per-day?
- Does the deductible apply to RB-BHT, and is there an out-of-pocket max that applies?

### VOB data sources

- https://provider.healthybluenc.com/docs/gpp/NCNC_CAID_ProviderManual.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://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.optum.com/content/dam/optum4/business/open_source/practice-management/professional-claims-payer-list.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.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://provider.healthybluenc.com/docs/gpp/HBNC_HBTC_TelehealthBillingCode.pdf (accessed 2026-07-23; source document older than 18 months)
- 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 Healthy Blue NC cover ABA therapy?

Yes — Healthy Blue administers NC Medicaid's RB-BHT benefit by adopting Clinical Coverage Policy 8F: PA on all services including assessment, authorization cycles tiered by intensity (180 calendar days at ≤16 hrs/week, 90 days above), LQASP treatment-plan reviews.

### How do I submit an RB-BHT authorization to Healthy Blue?

Via Availity Essentials' Interactive Care Reviewer, or fax (844) 429-9636 for outpatient behavioral health. Check the Precertification Lookup Tool for code-level requirements first.

### What is Healthy Blue Care Together?

The separate Children & Families Specialty Plan (launched December 2025) for child-welfare-involved members, also run by Blue Cross NC. Foster families' "Healthy Blue" cards may actually be CFSP — verify before submitting.

## Primary sources

1. [Healthy Blue NC — Provider Manual](https://provider.healthybluenc.com/docs/gpp/NCNC_CAID_ProviderManual.pdf)
2. [Healthy Blue NC — prior authorization page](https://provider.healthybluenc.com/north-carolina-provider/prior-authorization)
3. [NC Medicaid — Clinical Coverage Policy 8F](https://medicaid.ncdhhs.gov/8f-research-based-behavioral-health-treatment-rb-bht-autism-spectrum-disorder-asd/open)
4. [TRICARE — Using Other Health Insurance (updated 10/17/2025)](https://www.tricare.mil/Plans/OHI)
5. [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.