---
title: Partners Health Management ABA coverage (NC Tailored Plan).
url: "https://carelu.com/payers/partners-health-management"
markdown_url: "https://carelu.com/payers/partners-health-management.md"
state: NC (North Carolina)
payer: Partners Health Management (NC Tailored Plan)
kind: Medicaid managed care plan (MCO)
parent_program: North Carolina Medicaid
description: "How Partners Health Management administers NC Medicaid RB-BHT (ABA) — CCP 8F adoption, the provider-friendly ALL-codes authorization model in ProAuth, and the recoupment caveat that comes with it."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Partners Health Management ABA coverage (NC Tailored Plan).

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

> Tailored Plan with the ALL-codes authorization: one auth covers every RB-BHT code via ProAuth.

Partners Health Management, a Tailored Plan, adopts NC's clinical coverage policies outright for medical-necessity decisions — 8F included — and runs the most provider-friendly authorization model in the state: since October 2023, RB-BHT authorizations issue as "ALL codes," meaning one authorization on the base code covers every RB-BHT service code and modifier combination, telehealth included. The flexibility is real; so is the caveat that billing outside the approved treatment plan risks recoupment.

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 adopted CCP 8F [1][3]
- **Prior auth for treatment**: Required — one "ALL codes" authorization on the base code covers every RB-BHT code/modifier [2]
- **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 Tailored Plan (public LME/MCO)
- **Clinical rules:** CCP 8F adopted for medical-necessity decisions
- **Prior auth:** Required — single ALL-codes authorization per member
- **Portal:** ProAuth (base code as Primary Procedure Code on Prescreen)
- **UM contact:** UMQuestions@partnersbhm.org
- **Rates:** ≥100% of the NC Medicaid fee schedule (state floor)

## The ALL-codes authorization model

Instead of code-by-code authorizations, Partners issues one authorization covering all RB-BHT codes and modifiers: submit via ProAuth entering the base code as the Primary Procedure Code on the Prescreen and selecting the Treatment Type from the dropdown; authorizations are then visible in both ProAuth and Alpha. Operationally this means clinical teams can flex between assessment, direct treatment, supervision, and parent training without new requests — but every billed unit must still trace to the approved treatment plan, because Partners pairs the flexibility with post-payment review and recoupment for out-of-plan billing. [2][1]

Partners also runs an Autism Services Learning Collaborative for its network ABA providers, and its Tailored Plan documentation cross-references Carolina Complete Health policies through a Centene infrastructure partnership. [2][1]

## Intake gates

The questions that decide whether a family can start with Partners Health Management (NC Tailored Plan), 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][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. [3][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. [3][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). [3][2]
- **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 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]
- **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][2]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: "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]

## Delivery and billing rules

Coverage decides whether Partners Health Management (NC Tailored Plan) 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][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. [3][2]
- **Daily limits / MUEs**: 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]
- **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][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. [3][2]
- **Bill as provider**: 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]

## What intake should collect for Partners Health Management (NC Tailored Plan)

- **Treatment-plan alignment:** The ALL-codes auth only protects billing that matches the approved plan — keep the plan current as services shift.
- **ASD diagnosis + validated tool:** Per adopted CCP 8F, with the MD/DO/LP service order.
- **ProAuth setup:** Base code on the Prescreen, Treatment Type from the dropdown — train the intake/billing handoff on it once.

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

## Verification of benefits (VOB) data

How Partners Health Management (NC Tailored Plan) ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Behavioral health administrator:** none
- **ABA rides on:** behavioral health benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required — ONE "ALL codes" authorization on the base code (submitted via ProAuth, base code as Primary Procedure Code on the Prescreen, Treatment Type selected from the dropdown) covers every RB-BHT code and modifier combination, telehealth included. Billing must still trace to the approved treatment plan or risk recoupment on post-payment review. | 180 days (initial + reauth, per CCP 8F auth cycle) | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | Yes — GT modifier for telehealth (audio-visual). Telephonic (KX) delivery is not permitted for this code per CCP 8F’s Attachment A code table. | GT (telehealth) |
| 97152 | Yes | Required — ONE "ALL codes" authorization on the base code (submitted via ProAuth, base code as Primary Procedure Code on the Prescreen, Treatment Type selected from the dropdown) covers every RB-BHT code and modifier combination, telehealth included. Billing must still trace to the approved treatment plan or risk recoupment on post-payment review. | 180 days (initial + reauth, per CCP 8F auth cycle) | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | Yes — GT modifier for telehealth (audio-visual). Telephonic (KX) delivery is not permitted for this code per CCP 8F’s Attachment A code table. | GT (telehealth) |
| 97153 | Yes | Required — ONE "ALL codes" authorization on the base code (submitted via ProAuth, base code as Primary Procedure Code on the Prescreen, Treatment Type selected from the dropdown) covers every RB-BHT code and modifier combination, telehealth included. Billing must still trace to the approved treatment plan or risk recoupment on post-payment review. | 180 days (initial + reauth, per CCP 8F auth cycle) | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | Yes — GT modifier for telehealth (audio-visual). Telephonic (KX) delivery is not permitted for this code per CCP 8F’s Attachment A code table. | GT (telehealth) |
| 97154 | Yes | Required — ONE "ALL codes" authorization on the base code (submitted via ProAuth, base code as Primary Procedure Code on the Prescreen, Treatment Type selected from the dropdown) covers every RB-BHT code and modifier combination, telehealth included. Billing must still trace to the approved treatment plan or risk recoupment on post-payment review. | 180 days (initial + reauth, per CCP 8F auth cycle) | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | Yes — GT modifier for telehealth (audio-visual). Telephonic (KX) delivery is not permitted for this code per CCP 8F’s Attachment A code table. | GT (telehealth) |
| 97155 | Yes | Required — ONE "ALL codes" authorization on the base code (submitted via ProAuth, base code as Primary Procedure Code on the Prescreen, Treatment Type selected from the dropdown) covers every RB-BHT code and modifier combination, telehealth included. Billing must still trace to the approved treatment plan or risk recoupment on post-payment review. | Inferred from Vaya’s statewide-pattern passthrough: up to 1 hour per 10 hours of 97153/97154 (10%). Not confirmed as a Partners-specific rule — the ALL-codes model may not enforce a distinct 97155 ratio at all. per 180 days (initial + reauth, per CCP 8F auth cycle) | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | Yes — GT modifier for telehealth (audio-visual). Telephonic (KX) delivery is not permitted for this code per CCP 8F’s Attachment A code table. | GT (telehealth) |
| 97156 | Yes | Required — ONE "ALL codes" authorization on the base code (submitted via ProAuth, base code as Primary Procedure Code on the Prescreen, Treatment Type selected from the dropdown) covers every RB-BHT code and modifier combination, telehealth included. Billing must still trace to the approved treatment plan or risk recoupment on post-payment review. | 180 days (initial + reauth, per CCP 8F auth cycle) | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | Yes — GT modifier for telehealth (audio-visual). Telephonic (audio-only, KX modifier) also allowed, but ONLY when the caregiver's physical/behavioral health status or an access barrier (transportation, technology) prevents in-person or telehealth participation (CCP 8F §3.1.2/3.2.5). | GT (telehealth), KX (telephonic, caregiver-barrier criteria only) |
| 97157 | Yes | Required — ONE "ALL codes" authorization on the base code (submitted via ProAuth, base code as Primary Procedure Code on the Prescreen, Treatment Type selected from the dropdown) covers every RB-BHT code and modifier combination, telehealth included. Billing must still trace to the approved treatment plan or risk recoupment on post-payment review. | 180 days (initial + reauth, per CCP 8F auth cycle) | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | Yes — GT modifier for telehealth (audio-visual). Telephonic (audio-only, KX modifier) also allowed, but ONLY when the caregiver's physical/behavioral health status or an access barrier (transportation, technology) prevents in-person or telehealth participation (CCP 8F §3.1.2/3.2.5). | GT (telehealth), KX (telephonic, caregiver-barrier criteria only) |
| 97158 | No — 97158 is not part of NC Medicaid's CCP 8F billable RB-BHT code set (97151–97157 only) | N/A | N/A per N/A | — | N/A | — |
| 0362T | No — 0362T is not part of NC Medicaid's CCP 8F billable RB-BHT code set (97151–97157 only) | N/A | N/A per N/A | — | N/A | — |
| 0373T | No — 0373T is not part of NC Medicaid's CCP 8F billable RB-BHT code set (97151–97157 only) | N/A | N/A per N/A | — | N/A | — |

Code notes:

- **97158, 0362T, 0373T:** Confirmed absent from CCP 8F's own CPT code table (Attachment A), from Alliance's and Trillium's posted rate schedules, and from Vaya's authorization guidelines and rate schedule — checked directly, not assumed from the CPT list.

### Medicaid rates

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97158 | N/A | N/A — not part of NC’s CCP 8F billable code set | — |
| 0362T | N/A | N/A — not part of NC’s CCP 8F billable code set | — |
| 0373T | N/A | N/A — not part of NC’s CCP 8F billable code set | — |

### Contacts

- **Provider services phone:** 1-877-398-4145
- **Portal:** [Partners ProviderCONNECT Portal](https://providers.partnersbhm.org/category/providerconnect/)

Questions to ask on a verification call:

- What is Partners' payer ID for 270/271 eligibility checks — confirmed NOT 68069 (Carolina Complete Health's physical-health ID) — what do you actually use?
- What are the per-code unit caps for 97151-97157 under the single ALL-codes authorization?
- Is there a copay or coinsurance for RB-BHT, and if so is it per-visit or per-day?
- Does the deductible apply to RB-BHT, and is there an out-of-pocket max?
- What STC bucket does Partners return ABA benefit detail under on a 270/271 eligibility response?

### VOB data sources

- 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)
- https://network.carolinacompletehealth.com/content/dam/centene/carolinacompletehealth/pdfs/Partners-Carolina-Complete-Health-FAQ-General-Topics-3.7.24.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://medicaid.ncdhhs.gov/documents/files/8f-1/open (accessed 2026-07-23)
- https://providers.partnersbhm.org/authorizations-for-research-based-behavioral-health-treatment-transition-to-all-codes/ (accessed 2026-07-23)
- https://providers.vayahealth.com/wp-content/uploads/2025/05/RB_BHT_Guidance_20250522.pdf (accessed 2026-07-23)
- https://www.alliancehealthplan.org/document-library/97251 (accessed 2026-07-23)
- https://www.trilliumhealthresources.org/sites/default/files/docs/Billing-Codes-Rates/Trillium-Rate-Table-FY-26-27.pdf (accessed 2026-07-23)
- https://providers.vayahealth.com/wp-content/uploads/2025/09/Authorization_Guidelines_Medicaid_RB_BHT_ASD.pdf (accessed 2026-07-23)
- https://www.partnersbhm.org/tailoredplan/providers/manuals-forms-and-policies/clinical-coverage-policies/ (accessed 2026-07-23)
- https://providers.partnersbhm.org/provider-network-contacts/ (accessed 2026-07-23)

## Common questions

### Does Partners Health Management cover ABA therapy?

Yes — as a Tailored Plan it adopts CCP 8F for RB-BHT medical-necessity decisions, with prior authorization required per the state baseline.

### What is the ALL-codes authorization?

Since October 2023, one Partners authorization on the base code covers all RB-BHT codes and modifiers — no code-by-code requests. Billing must still match the approved treatment plan or risk recoupment.

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

Through ProAuth: enter the base code as the Primary Procedure Code on the Prescreen, select the Treatment Type from the dropdown. Questions go to UMQuestions@partnersbhm.org.

## Primary sources

1. [Partners — Tailored Plan clinical coverage policies](https://www.partnersbhm.org/tailoredplan/providers/manuals-forms-and-policies/clinical-coverage-policies/)
2. [Partners — ALL-codes authorization provider alert](https://providers.partnersbhm.org/authorizations-for-research-based-behavioral-health-treatment-transition-to-all-codes/)
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. [Partners Health Management — 2025-2026 Provider Operations Manual (rev. 20250623)](https://providers.partnersbhm.org/wp-content/uploads/partners-provider-operations-manual.pdf)
5. [Partners — Provider Communication Bulletin #172 (CMS prior-auth timeframes postponed to 7/1/2026)](https://providers.partnersbhm.org/provider-communication-bulletin-172/)
6. [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)
7. [TRICARE — Using Other Health Insurance (updated 10/17/2025)](https://www.tricare.mil/Plans/OHI)
8. [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.