---
title: Trillium Health Resources ABA coverage (NC Tailored Plan).
url: "https://carelu.com/payers/trillium-health-resources"
markdown_url: "https://carelu.com/payers/trillium-health-resources.md"
state: NC (North Carolina)
payer: Trillium Health Resources (NC Tailored Plan)
kind: Medicaid managed care plan (MCO)
parent_program: North Carolina Medicaid
description: "How Trillium Health Resources administers NC Medicaid RB-BHT (ABA) — its benefit-plan service definition citing CCP 8F, 180-day TAR cycles, adult coverage under the 2021 SPA, and telehealth modifier rules."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Trillium Health Resources ABA coverage (NC Tailored Plan).

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

> Tailored Plan with the best single reference doc: tiered 180/90-day TARs, adult coverage, GT/KX modifier rules.

Trillium Health Resources, an eastern-NC Tailored Plan, publishes the single best reference document of the four Tailored Plans: a Medicaid Child Behavioral Health Benefit Plan (revised July 2026) carrying a complete RB-BHT service definition that cites CCP 8F and the 2021 State Plan Amendment as its sources. Nothing in it is clinically distinct from the state baseline — which is exactly what makes it a reliable operational reference for TAR submissions.

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 — TAR (prior authorization) on all RB-BHT codes, telehealth included [1][2]
- **Prior auth for treatment:** Not published / unverified. Verify via: Trillium's Medicaid Child BH Services Benefit Plan, next revision. This value's flat ‘up to 180 days each’ predates the 8/1/2026 CCP 8F rewrite — §5.1 is tiered (up to 180 calendar days at ≤16 hrs/week, up to 90 above it), and this guide's own prose already states the tiering. Reconcile the two before relying on either. [2]
- **Autism diagnosis required?**: Yes — ASD via a validated diagnostic tool; under-3s may start on a provisional diagnosis [2]

## At a glance

- **Plan type:** NC Tailored Plan (public LME/MCO, eastern NC)
- **Clinical rules:** CCP 8F via its benefit-plan service definition
- **Prior auth:** TAR required on all codes 97151–97157, telehealth included
- **Auth periods:** Tiered by intensity per CCP 8F §5.1/5.1.1 — up to 180 calendar days at ≤16 hrs/week, up to 90 above; renew before expiry
- **Ages:** "Children, Adolescents and Adults" — reflects the 21+ SPA coverage
- **Rates:** ≥100% of the NC Medicaid fee schedule (state floor)

## How Trillium runs RB-BHT authorization

Every RB-BHT code (97151–97157) requires a TAR — prior authorization — including telephonic and telehealth delivery. The initial request needs the written assessment, diagnosis documentation from a validated tool, and the MD/DO/LP service order; treatment requests add a complete treatment plan signed by the LQASP and the legally responsible person, plus a discharge plan. Under the finalized CCP 8F (effective 8/1/2026), plans at or under 16 hours/week keep 180-day initial and reauthorization periods, while plans above 16 hours/week move to 90-day initial and reauthorization periods; reauth is due before the current one expires either way, and all services are subject to post-payment review. Existing prior authorizations aren't affected by the change — no action is needed, and no existing PA's duration will be reduced; the new 90-day cadence binds only future reauthorizations. Units run in 15-minute increments with no published unit caps. [1][2][3]

Telehealth mechanics, now finalized under CCP 8F effective August 1, 2026: telehealth is removed entirely — no documented-necessity exception — for the paraprofessional-delivered codes 97152, 97153, and 97154. 97151 retains telehealth eligibility with clinical justification, and 97155 retains it but capped at a maximum of 50% of total 97155 billing per beneficiary per 180-calendar-day period. 97156/97157 keep their own separate telephonic/KX caregiver-access-barrier exception, unchanged. LOCUS/CALOCUS is no longer required, but a standardized assessment tool is still expected. [1][2][3]

## Intake gates

The questions that decide whether a family can start with Trillium Health Resources (NC Tailored Plan), and what they have to bring.

- **Age limit**: 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]
- **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. [2][1]
- **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. [2][1]
- **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). [2][1]
- **Referral required?**: 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]
- **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. [2][1]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: 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]

## Delivery and billing rules

Coverage decides whether Trillium Health Resources (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. [2][1]
- **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. [2][1]
- **Daily limits / MUEs**: 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]
- **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. [2][1]
- **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. [2][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. [2][1]

## What intake should collect for Trillium Health Resources (NC Tailored Plan)

- **Assessment + service order:** Written assessment, validated-tool diagnosis documentation, and the MD/DO/LP order — all required at the initial TAR.
- **Signatures:** Treatment plans need the LQASP and the legally responsible person's signatures.
- **Reauth calendar:** 180-day cycles for plans ≤16 hrs/week, 90-day cycles for plans >16 hrs/week (per the finalized CCP 8F, eff. 8/1/2026), with renewal due before expiry — put it on the calendar at intake.
- **Age:** Trillium's benefit plan covers adults too — don't screen out 21+ inquiries reflexively.

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

## Verification of benefits (VOB) data

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

### EDI routing

- **Payer ID (Change Healthcare / Optum):** 56089
- **Behavioral health administrator:** none — Trillium is itself the LME/MCO administering behavioral health (including RB-BHT) directly — inferred from its role as a Tailored Plan and from its own claims protocol routing BH claims in-house (not to a third-party administrator).
- **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 — TAR (initial + reauth up to 180 days each, telehealth included); reauth due before current auth expires | 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 — TAR (initial + reauth up to 180 days each, telehealth included); reauth due before current auth expires | 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 — TAR (initial + reauth up to 180 days each, telehealth included); reauth due before current auth expires | 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 — TAR (initial + reauth up to 180 days each, telehealth included); reauth due before current auth expires | 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 — TAR (initial + reauth up to 180 days each, telehealth included); reauth due before current auth expires | Inferred from Vaya’s statewide-pattern passthrough: up to 1 hour per 10 hours of 97153/97154 (10%); above that, medical-necessity review. Not confirmed as a Trillium-specific rule. 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 — TAR (initial + reauth up to 180 days each, telehealth included); reauth due before current auth expires | 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 — TAR (initial + reauth up to 180 days each, telehealth included); reauth due before current auth expires | 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:

- **97151:** No published unit caps (per the base corpus prose); units run in 15-minute increments. Inferred from Vaya’s statewide pattern: other Tailored Plans notify-approve up to 32 units/6 months before requiring medical-necessity review.
- **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

Source: Trillium Health Resources — Rate Table FY 26-27 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 | — |
| 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:** 866-998-2597
- **Phone menu path:** Listed as "Business & Administrative Matters" in the Claims Submission Protocol's Tailored Plan Medicaid contact block; "Member & Recipient Services" (877-685-2415) is the separate member-facing line — do not use it for provider calls.
- **Portal:** [Trillium Provider Direct Portal](https://www.trilliumhealthresources.org)

Questions to ask on a verification call:

- Do you support real-time 270/271 eligibility checks, and what is your Availity/pVerify payer ID — neither is found on their national lists?
- What are Trillium's per-code unit caps for 97151-97157, beyond the 180-day TAR cycle?
- 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 Trillium 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://www.trilliumhealthresources.org/sites/default/files/docs/Provider-documents/Claims/Trillium-Medicaid-Direct-Tailored-Plan-Claims-Submission-Protocol.pdf (accessed 2026-07-23)
- https://www.trilliumhealthresources.org/sites/default/files/docs/Benefit-Plans-Services-Definitions/Trillium-Medicaid-Child-BH-Benefit-Plan.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.vayahealth.com/wp-content/uploads/2025/09/Authorization_Guidelines_Medicaid_RB_BHT_ASD.pdf (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)

## Common questions

### Does Trillium cover ABA therapy?

Yes — RB-BHT under CCP 8F, with a TAR (prior authorization) required for every code including telehealth delivery, in 180-day cycles (90-day for plans above 16 hours/week under the finalized 8F, effective 8/1/2026).

### Does Trillium cover ABA for adults?

Its benefit plan lists RB-BHT for "Children, Adolescents and Adults," reflecting the 2021 State Plan Amendment that extended NC RB-BHT coverage past age 21.

### Can Trillium ABA services be delivered by telehealth?

Only in part, under the finalized CCP 8F (effective 8/1/2026): telehealth is removed entirely for 97152, 97153, and 97154; 97151 keeps it with clinical justification; 97155 keeps it capped at 50% of billing per beneficiary per 180 days; 97156/97157 keep their separate telephonic/KX caregiver-barrier exception.

## Primary sources

1. [Trillium — Medicaid Child BH Services Benefit Plan](https://www.trilliumhealthresources.org/sites/default/files/docs/Benefit-Plans-Services-Definitions/Trillium-Medicaid-Child-BH-Benefit-Plan.pdf)
2. [NC Medicaid — Clinical Coverage Policy 8F](https://medicaid.ncdhhs.gov/8f-research-based-behavioral-health-treatment-rb-bht-autism-spectrum-disorder-asd/open)
3. [NC Medicaid — Updated reminder: RB-BHT service delivery requirements (8/31/2026)](https://medicaid.ncdhhs.gov/blog/2026/08/31/updated-reminder-requirements-research-based-behavioral-health-treatment-service-delivery-aug-31)
4. [Trillium Health Resources — BH I/DD Tailored Plan/PIHP Provider Manual (eff. 7/20/2026)](https://www.trilliumhealthresources.org/sites/default/files/docs/Provider-documents/Provider-Manual/Trillium-TP-Provider-Manual.pdf)
5. [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)
6. [Trillium — Claims Billing Guide 2026](https://www.trilliumhealthresources.org/sites/default/files/docs/Provider-documents/Claims/Trillium-Claims-Billing-Guide.pdf)
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.