Trillium Health Resources ABA coverage (NC Tailored Plan).

Follows the NC Medicaid rule — no upper age bound. Trillium is explicit about it: its Medicaid Child Behavioral Health Benefit Plan lists RB-BHT for "Children, Adolescents and Adults," reflecting the 2021 State Plan Amendment that extended coverage past 21. Under-21 members carry EPSDT; under-3s may start on a provisional diagnosis.^[2][1][1]

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.^[2][1]

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.^[2][1]

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).^[2][1]

Follows the NC Medicaid rule, enforced at the TAR: the initial request needs the written assessment, diagnosis documentation from a validated tool, and the MD/DO/Licensed Psychologist service order; treatment requests add a complete treatment plan signed by the LQASP and the legally responsible person, plus a discharge plan. Every RB-BHT code (97151–97157) requires a TAR, telehealth and telephonic delivery included.^[2][1][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.^[2][1]

Trillium’s July 2026 manual lists "7 calendar days for a routine request" and "72 hours for an expedited request" alongside timely responses to Treatment Authorization Requests (TARs), and says formal decisions are made only "when a complete request is received." Submit TARs "at least 7 days prior to the end date of the current authorization"; for RB-BHT the benefit plan adds "Reauth must be submitted prior to initial or concurrent auth expiring" (up to 180 days at 16 hours a week or fewer, up to 90 above). A service cannot be authorized "if requested more than 30 days in advance." The 7-day figure matches the federal managed-care ceiling for NC plans from July 1, 2026.^[4][1][5]

Trillium pays last, and it answers the secondary-auth question the opposite way to most plans: "The requested service cannot be authorized if the member has private insurance, and the provider should seek authorization from primary insurance source. Medicaid is the payor of last resort." So for a child with commercial coverage, get the ABA authorization from the commercial plan, "Bill all first - and third-party payers prior to submitting claims to Trillium", and record the other payer’s payment or denial on the claim (keep the EOB). Claims go to the primary insurer first, "then secondary insurance after the initial EOB has been received." Exceptions paid without TPL first include medical support enforcement (coverage through an absent parent) and "Preventive Pediatric Services including … EPSDT". Under federal rules TRICARE pays before Medicaid and CHAMPVA pays first when the child is also Medicaid-eligible.^{[1][4][6][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.^[2][1]

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.^[2][1]

Follows the NC Medicaid rule. Trillium states there are no published unit caps — units run in 15-minute increments — so the binding limits are the authorization periods: 180-day initial and reauthorization cycles at or under 16 hours a week, 90-day cycles above it, with reauthorization due before the current one expires and all services subject to post-payment review. Existing prior authorizations are unaffected by the change and none will be shortened.^[2][1][1][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.^[2][1]

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.^[2][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.^[2][1]