North Carolina Medicaid ABA coverage: the intake guide.

No upper age bound in the policy. The 8/1/2026 rewrite struck the phrase "under 21 years of age" from the eligibility provision at subsection 2.1.2, and a 2021 State Plan Amendment extends RB-BHT to adults 21 and older. Under-21 beneficiaries additionally carry the EPSDT special provision (42 U.S.C. § 1396d(r)), under which limits on scope, amount, duration, frequency and location of service may be exceeded where documentation shows the service is medically necessary to correct or ameliorate the condition. At the bottom end, beneficiaries under three years of age at the time services begin may start on a provisional diagnosis.^[6]

CCP 8F sets no expiry date on the ASD diagnosis itself — medical necessity requires a "current ASD diagnosis" recognised by the current edition of the DSM. Two clocks do run. A beneficiary who started under age three on a provisional diagnosis must have a non-provisional ASD diagnosis within six months of the provisional one, or the provider implements transition or discharge. And at least one adaptive behavior assessment must have been completed within the last 3 years. The provider must verify and hold documentation of a qualifying ASD diagnosis before initiating RB-BHT; services rendered without adequate diagnostic documentation are subject to denial, recoupment or termination.^[6]

Non-provisional ASD diagnosis: a Licensed Psychologist (where an autism diagnosis is within their experience and competence under Article 18G of the Psychology Practice Act), a Licensed Psychological Associate with the required supervision, or a physician (MD or DO) acting within their legal NC scope. An evaluation by a Licensed School Psychologist that includes any or all of the required testing may be used to meet the diagnostic criteria where there is no clinical indication to repeat testing. A provisional diagnosis for an under-3 may additionally be made by a licensed clinician with at least a master’s degree who has completed the training and supervision to administer validated ASD instruments and for whom this is within scope.^[6]

The non-provisional ASD diagnosis must be made with one of four named instruments (or later versions): Brief Observation of Symptoms of Autism (BOSA), Tele-ASD-Peds (TAP), ADOS-2, or CARS2-ST / CARS2-HF. Services may not be initiated on screening tools, educational determinations or informal clinical impressions alone. The authorization packet also needs a skills assessment using VB-MAPP, ABLLS-R or the ESDM Curriculum Checklist, a functional behavior assessment (or functional behavioral analysis at provider option) where challenging behaviors are targeted, and an adaptive behavior assessment completed within the last 3 years — VABS-3, ABAS-3 or DP-4. An alternative instrument may be substituted with clinical justification where the required one is not clinically indicated.^[6]

Yes — a written service order completed and signed by a Licensed MD, Licensed DO or Licensed Psychologist working within scope, signed and dated with the date the service was ordered. It must be in place prior to or on the day the service is first provided, must rest on a behavioral, adaptive or functional assessment plus a treatment plan built from that assessment, and is valid for one year: medical necessity must be reconfirmed and services re-ordered annually from the date of the original order. 97151 and 97152 do not require a service order or treatment plan for prior approval; a service order must be in place before 97153, 97154, 97155, 97156 or 97157.^[6]

Per code, under Attachment A of the 8/1/2026 policy. Telehealth billable with modifier GT: 97151, with clinical justification recorded in the treatment plan; and 97155, capped at a maximum of 50% of total 97155 billing per beneficiary per 180-calendar-day period, with clinical justification in the treatment plan if more telehealth units are needed. Not telehealth billable at all: 97152, 97153 and 97154. 97156 and 97157 are telehealth eligible and are additionally the only telephonic (audio-only, modifier KX) services, allowed where the caregiver’s physical or behavioral health status, or an access barrier such as transportation or technology, prevents in-person or telehealth participation. Telehealth and telephonic claims are filed with the provider’s usual place-of-service code, and delivery follows Clinical Coverage Policy 1-H.^[6]

NC Medicaid Direct (fee-for-service): the state’s prior-approval page says Medicaid "will make every effort possible to make a decision within 15 business days of receipt of the request unless there is a more stringent requirement" — and a more stringent one now exists: since January 1, 2026, 42 CFR 440.230(e) requires state fee-for-service decisions within 7 calendar days for a standard request (extendable up to 14 calendar days when more information is needed) and 72 hours for an expedited one. Health plans (Standard, Tailored, CFSP): the federal managed-care ceiling is 7 calendar days standard for rating periods starting on or after January 1, 2026 — NC’s rating period starts July 1, so from July 1, 2026 — plus up to 14 extension days, and 72 hours expedited; the posted Standard Plan contract text still reads "no later than fourteen (14) calendar days following receipt of the request", and plan manuals vary (see each plan). Reauthorization: CCP 8F says "Reauthorization must be submitted prior to initial or concurrent authorization expiring" (every 180 days at ≤16 hrs/week, every 90 above), and NC Medicaid asks providers to "request authorization of a continuing services 10 calendar days before the end of the current authorization period" so services continue during any adverse-decision notice period.^{[18][19][20][21][22][6]}

Medicaid pays last. "Medicaid is the 'payer of last resort' by federal law" — Medicare and private carriers "must process a claim before Medicaid processes a claim." CCP 8F restates it for RB-BHT: providers "shall bill all other third-party payers, including Medicare, before submitting a claim for Medicaid reimbursement." Ask about other coverage before the first session; where it shows on the NCTracks record "the provider must bill the carrier before billing Medicaid" and must hold the primary carrier’s EOB with the payment or denial, then file with Medicaid within 180 days of that EOB date. A denial the provider caused with the other plan cannot be overridden at Medicaid — fix it with that carrier. Prior approval still applies: CCP 8F requires prior approval before rendering RB-BHT and makes no exception for members with other insurance. Pay-and-chase: health plans pay first and recover for EPSDT and, per the state’s plan billing guidance, "If a prior authorization is approved as EPSDT medical necessity, health plans should pay and chase for all claims related to this prior authorization"; RB-BHT codes are not on the TPL bypass list. Federal program order: TRICARE pays after all other health insurance except Medicaid (so TRICARE pays before Medicaid), and CHAMPVA pays first when the member is also Medicaid-eligible.^{[23][6][24][25][26][27]}

At least ten percent of all services delivered by a paraprofessional must involve observation and direction of that paraprofessional by a Licensed Qualified Autism Service Provider (LQASP). For a beneficiary receiving more than 200 hours of paraprofessional-delivered RB-BHT in a 180-calendar-day period, the ratio of LQASP-delivered to paraprofessional-delivered hours must be no less than 1:10 (10%) and no more than 2:10 (20%), measured over the authorization period and documented in the treatment plan; any plan requesting a ratio outside that band needs written clinical justification. Incidental supervision — ensuring competent, ethical practice, adherence to employer policy, ongoing skill development and personal support — is not billable.^[6]

Yes, in one direction only. 97153 and 97154 may be billed concurrently with 97155 when the paraprofessional is delivering the direct service and an eligible provider is observing; 97155 may be billed concurrently with 97153 or 97154. A single rendering provider may not bill 97153 or 97154 and 97155 simultaneously. 97151, 97152, 97156 and 97157 carry no concurrent-billing allowance. Separately, a non-RB-BHT Medicaid service may not be billed at the same time as an RB-BHT service, though same-day delivery is allowable.^[6]

CCP 8F publishes no per-day unit ceiling — every RB-BHT code bills in 15-minute units and Attachment A carries no daily maximum. The binding limits are per authorization period: treatment plans at 16 hours per week or fewer get up to 180 calendar days initial and reauthorize at least every 180 days, while plans above 16 hours per week get up to 90 calendar days and must be reviewed, modified and resubmitted at least every 90 days. Within a 180-day period, 97155 telehealth is capped at 50% of total 97155 billing, the LQASP-to-paraprofessional ratio band is 10–20% once paraprofessional hours pass 200, and a minimum of six caregiver training sessions must be completed. Hours spent in educational settings and receiving IEP services are excluded from the treatment-hour calculation.^[6]

The staff member who provides the service signs the written entry, and the signature documents credentials for a professional or a job title for a paraprofessional. Notably, an LQASP or Certified Qualified Professional is NOT required to countersign a service note written by staff who hold neither status. A full service note is required for each contact or intervention on each date of service, carrying beneficiary name, Medicaid ID, date, service name, type of contact, place of service, purpose against a treatment-plan goal, description of the intervention, duration with session time in and out, assessment of effectiveness with data collected, caregivers present, a plan-of-care or protocol modification note for 97155, and the signature, date and credentials or job title of the staff member — with the beneficiary name, Medicaid ID and record number on every page. The treatment plan itself must be signed and dated by the responsible LQASP and the person consenting to treatment before services are delivered.^[6]

Clinic, office, home, school and community settings are all payable, in any combination across the course of treatment, with the place-of-service decision documented in the treatment plan, made individually in collaboration with the family, and clinically justified for each location; where treatment starts in a structured clinic setting the goal is to advance into the beneficiary’s natural settings. Team members may not appear at a beneficiary’s place of work without prior permission. Services available through IDEA or other educational programs that duplicate or supplant the authorized treatment plan are not covered, nor is 1:1 support that substitutes for educational personnel. Telehealth and telephonic claims are filed with the provider’s usual place-of-service code.^[6]

A professional claim (CMS-1500 / 837P) billed through the beneficiary’s health plan or its dedicated vendor. Attachment B fixes who may render each code: 97151 by a physician, Licensed Psychologist / Licensed Psychological Associate or Licensed Behavior Analyst; 97152, 97153 and 97154 by a behavior technician under the direction of one of those practitioners or an LaBA, or by the practitioner directly; 97155 by a physician, psychologist, LBA or LaBA (non-licensed analysts only under required supervision); 97156 and 97157 by a physician, psychologist or LBA. Behavior technicians must be certified as an RBT (BACB) or ABAT (QABA) and produce evidence to the agency within 120 calendar days of hire or of the agency’s first Medicaid enrollment, whichever is later, and must stop rendering if they miss that window. The agency must be enrolled with NC Medicaid through NCTracks, and per NC Medicaid’s August 2026 reminder all LQASPs and C-QPs must enroll as in-state providers as of August 2, 2026.^[6][7]