Partners Health Management ABA coverage (NC Tailored 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][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.^[3][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.^[3][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).^[3][2]

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 a behavioral/adaptive/functional assessment and treatment plan, valid one year and re-ordered annually. 97151 and 97152 need no service order for prior approval; 97153–97157 do.^[3][2]

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][2]

Partners’ operations manual: "Partners must decide and provide notice within 14 calendar days of receiving a standard request for authorization of service with a possible extension of an additional 14 calendar days", and within 72 hours for expedited requests (expedited concurrent within 24 hours). Its January 2026 bulletin says the CMS prior-authorization timeframes "have been postponed to July 1, 2026" — from then the federal ceiling is 7 calendar days standard, so expect 7 now and confirm with Partners UM. "Services are expected to be requested on or before the start date"; a request submitted more than 30 days before the start date is administratively denied. CCP 8F requires the RB-BHT reauth before the current authorization expires.^[4][5][6][3]

"Federal and state regulations require Medicaid to be the payer of last resort": Medicare and private carriers "must process the claim before Partners processes a Medicaid claim", and "Medicaid claims submitted without third-party information will be denied." Partners pays only the gap up to its contracted rate, and "will not pay for any service that could have been paid for by Medicare or other private insurance plans had the member or provider complied with the plan's requirements" — including failure to obtain the other plan’s prior approval — so follow the commercial plan’s ABA precert rules to the letter. Codes on Partners’ TPL/Medicare bypass list skip the other payer; no RB-BHT code is on it. 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][3][7][8]

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][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.^[3][2]

Follows the NC Medicaid rule — no per-day unit ceiling, limits set per authorization period. Partners’ own model is unusually permissive on codes: since October 2023 one authorization on the base code covers every RB-BHT code and modifier combination, telehealth included, submitted through ProAuth with the base code as Primary Procedure Code on the Prescreen. The flexibility is paired with post-payment review — every billed unit must trace to the approved treatment plan or face recoupment.^[3][2][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.^[3][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.^[3][2]

Follows the NC Medicaid rule on rendering-provider eligibility, the professional claim and the 120-day RBT/ABAT certification clock. Partners issues authorizations as "ALL codes" on the base code, so the claim’s code and modifier can flex within the approved treatment plan without a new request — but billing outside that plan is recouped.^[3][2][2]