UnitedHealthcare Community Plan of North Carolina ABA coverage (Standard 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]

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]

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]

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]

Follows the NC Medicaid rule for the service order itself — MD/DO/Licensed Psychologist, dated on or before the first service, valid one year — but the authorization flow is Optum’s: since July 1, 2021 Optum manages the plan’s ABA network and requires an authorization for the assessment that is separate from the treatment authorization, both submitted through Provider Express with a One Healthcare ID. Sequence intake as benefits check, assessment auth, assessment, treatment auth, with the 8F diagnosis and service order satisfied before step one.^[3][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.^[3]

UHC Community Plan of NC’s 2026 manual already runs the 7-day clock: non-urgent pre-service decisions come "As quickly as the member's condition requires but no longer than 7 calendar days of request receipt", urgent/expedited "Within 72 hours of request receipt", concurrent review "Within 24 hours or next business day", and retrospective review within 30 calendar days of receiving all pertinent clinical information. The manual asks for non-emergency outpatient PA at least 14 business days ahead; RB-BHT (managed by Optum) needs PA on 97152–97157. CCP 8F requires the reauth before the current authorization expires.^[4][3]

"UnitedHealthcare Community Plan is, by law, the payer of last resort": bill and obtain an EOB from the other coverage first, then submit to UHC with the complete EOB showing the paid amount or denial reason, "within 180 calendar days from the primary insurer's explanation of benefits/remittance advice date (whether the claim was paid or denied)." The manual lists no pay-and-chase services of its own; the state’s plan billing guidance requires plans to pay and chase EPSDT and claims under a PA "approved as EPSDT medical necessity." 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][5][3][6][7]}

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]

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]

Follows the NC Medicaid rule: no per-day unit ceiling is published — the limits are per authorization period. Plans at or under 16 hours a week run 180-day initial and reauthorization cycles; plans above 16 hours a week run 90-day cycles. Within a 180-day period, 97155 telehealth is capped at 50% of 97155 billing and at least six caregiver training sessions are required. Educational-setting and IEP hours are excluded from the treatment-hour calculation.^[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.^[3]

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]

Follows the NC Medicaid rule on rendering-provider eligibility and the professional CMS-1500/837P claim, with one credentialing dependency layered on: providers must be enrolled with NC Medicaid through NCTracks before they can join the Optum ABA network, and both enrolments must be in place before serving members.^[3][1]