Vaya Health 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.^[4][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.^[4][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.^[4][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).^[4][1]

Follows the NC Medicaid rule (MD/DO/Licensed Psychologist service order, assessment-based, dated on or before the start, valid one year), with Vaya-specific passthrough thresholds that decide whether a full service authorization request is needed: 97151 up to 32 units per six months passes through on notification alone, and above that needs a complete SAR carrying the service order, treatment plan and MD/DO/psychologist-validated ASD diagnosis. 97152, 97153, 97154, 97156 and 97157 always need a SAR with FBA, treatment plan and service order on both initial and concurrent requests.^[4][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.^[4][1]

Vaya: "Vaya will issue a decision and provide notice within 14 calendar days of receipt of the request", extendable up to 14 more calendar days, and expedited requests "within 72 hours following acceptance of an expedited request." When information is missing, providers "have up to three business days to submit any requested additional information" or the request is returned. Lead time is explicit: "Submit SARs at least 14 days before the end of the existing authorization … to avoid a gap in authorization or payment." The federal managed-care ceiling for rating periods starting on or after January 1, 2026 is 7 calendar days standard, which reaches NC plans from July 1, 2026 — after Vaya’s March 2026 manual, so expect 7 and confirm with Vaya UM. RB-BHT authorizations run 180 days at 16 hours a week or fewer, 90 above.^[3][5][6][7]

"Medicaid is the payor of last resort. Providers are required to collect all first- and third-party funds prior to submitting claims to Vaya." Wait a reasonable time for the other payer, keep its RA/EOB or other proof of payment or denial, and bill Vaya only the remaining amount; such claims are due "within 180 days of the date you receive a remittance from a first- or second-party payor." Where the member also uses state-funded services, state funds pay last. 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.^[5][4][8][9]

Follows the NC Medicaid rule (10% LQASP observation floor; 10–20% LQASP-to-paraprofessional ratio above 200 paraprofessional hours per 180 days). Vaya adds an authorization threshold on top: 97155 protocol modification by a BCBA-LP passes through on notification alone up to a ratio of one hour per ten hours of direct intervention (97153/97154); above that ratio it needs a full SAR for medical-necessity review.^[4][1][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.^[4][1]

Follows the NC Medicaid rule — no per-day unit ceiling, with limits set per authorization period. Vaya’s own thresholds are the practical ones at intake: 97151 up to 32 units per six months and 97155 up to a 1-hour-per-10-hours ratio against direct intervention pass through on notification, and anything above either needs a full SAR.^[4][1][1]

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.^[4][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.^[4][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.^[4][1]