---
title: Vaya Health ABA coverage (NC Tailored Plan).
url: "https://carelu.com/payers/vaya-health"
markdown_url: "https://carelu.com/payers/vaya-health.md"
state: NC (North Carolina)
payer: Vaya Health (NC Tailored Plan)
kind: Medicaid managed care plan (MCO)
parent_program: North Carolina Medicaid
description: "How Vaya Health (Vaya Total Care) administers NC Medicaid RB-BHT (ABA) in western North Carolina — CCP 8F administration through SARs to Vaya UM, and which plan documents to pull from the provider portal."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Vaya Health ABA coverage (NC Tailored Plan).

_Payer Guide · Vaya Health (NC) · Last updated September 2026 · 4 primary sources_

> Western-NC Tailored Plan; 8F via SARs to Vaya UM — key documents must be pulled manually.

Vaya Health — operating the "Vaya Total Care" Tailored Plan across western North Carolina — administers RB-BHT as straight CCP 8F, with authorization running through service authorization requests (SARs) to Vaya's in-house UM team. Its provider-document library previously blocked automated access; as of this review its authorization guidelines are readable directly, and the code-level passthrough thresholds below are confirmed from Vaya's own document text rather than inferred.

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 8F; Vaya publishes RB-BHT authorization guidelines (v2.0, eff. 9/2025) on its provider portal [4][1]
- **Prior auth for treatment**: Required — service authorization requests (SARs) reviewed by Vaya UM against 8F medical necessity [1][4]
- **Autism diagnosis required?**: Yes — ASD via a validated diagnostic tool; under-3s may start on a provisional diagnosis [4]

## At a glance

- **Plan type:** NC Tailored Plan (public LME/MCO, western NC — "Vaya Total Care")
- **Clinical rules:** CCP 8F; Vaya RB-BHT authorization guidelines v2.0 (eff. 9/2025)
- **Prior auth:** Required — SARs to Vaya UM
- **UM contact:** (800) 893-6246 ext. 1513 · UM@vayahealth.com
- **Portal:** providers.vayahealth.com
- **Rates:** ≥100% of the NC Medicaid fee schedule (state floor); Vaya publishes its own rate schedule

## How Vaya administers RB-BHT

The clinical picture is the CCP 8F baseline: PA on all services including the 97151 comprehensive assessment (which Vaya's guidelines designate as LQASP-billed), authorization cycles tiered by intensity (180 calendar days at ≤16 hrs/week, 90 days above), and LQASP treatment-plan reviews. SARs submit through the provider portal and are reviewed by Vaya UM against medical necessity and the clinical coverage policy. [4][1][2]

Vaya's "Authorization Guidelines: Medicaid RB-BHT Services for ASD" (v2.0, rev. 9/5/2025 — still current, no v2.1/2026 update found) sets specific passthrough thresholds worth building into intake: 97151 assessment requests up to 32 units per six months go through as notification-only, without a full SAR, while requests above 32 units need a complete SAR (service order, treatment plan, MD/DO/psychologist-validated ASD diagnosis). 97155 (protocol modification by a BCBA-LP) similarly passes through on notification alone up to a 1-hour-per-10-hours ratio against direct intervention (97153/97154); above that ratio it needs a full SAR for medical-necessity review. All other codes (97152, 97153, 97154, 97156, 97157) require a SAR plus FBA, treatment plan, and service order on both initial and concurrent requests. A companion document, "RB-BHT Guidance" (v1.0, rev. 5/1/2025), restates the CCP 8F service definitions and clarifies "Program Modification vs. Supervision" for 97155. [4][1][2]

## Intake gates

The questions that decide whether a family can start with Vaya Health (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. [4][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. [4][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. [4][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). [4][1]
- **Referral required?**: 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]
- **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. [4][1]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: "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]

## Delivery and billing rules

Coverage decides whether Vaya Health (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 (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]
- **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. [4][1]
- **Daily limits / MUEs**: 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]
- **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. [4][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. [4][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. [4][1]

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

- **Member county:** Vaya's footprint is western NC — confirm the county maps to Vaya before intake.
- **ASD diagnosis + validated tool:** Per CCP 8F, with the MD/DO/LP service order.
- **Unit thresholds:** 97151 ≤32 units/6mo and 97155 ≤1hr-per-10hrs ratio pass through on notification only — above either, a full SAR is required.

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

## Verification of benefits (VOB) data

How Vaya Health (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 | Passthrough: notification SAR + service order, up to 32 units per 6 months; requests above 32 units reviewed for medical necessity. Above 32 units, Initial/Concurrent SAR + service order + clinical documentation validating ASD diagnosis via a scientifically validated tool required. | 32 units per 6 months (passthrough notification threshold; higher requests reviewed) 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) |
| 97152 | Yes | Initial: SAR + FBA + treatment plan + service order (annual) + clinical documentation validating ASD diagnosis. Concurrent: SAR + FBA + treatment plan + service order (annual). | 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 | Initial: SAR + FBA + treatment plan + service order (annual) + clinical documentation validating ASD diagnosis. Concurrent: SAR + FBA + treatment plan + service order (annual). | 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 | Initial: SAR + FBA + treatment plan + service order (annual) + clinical documentation validating ASD diagnosis. Concurrent: SAR + FBA + treatment plan + service order (annual). | 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 | Passthrough: notification SAR, up to 1 hour per 10 hours of direct intervention (97153/97154) — i.e. 10%. Requests for a higher ratio: SAR + service order + clinical documentation validating ASD diagnosis + FBA + treatment plan, reviewed for medical necessity. | 1 hour per 10 hours of 97153/97154 (10% passthrough threshold; higher ratios reviewed) 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 | Initial: SAR + FBA + treatment plan + service order (annual) + clinical documentation validating ASD diagnosis. Concurrent: SAR + FBA + treatment plan + service order (annual). | 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 | Initial: SAR + FBA + treatment plan + service order (annual) + clinical documentation validating ASD diagnosis. Concurrent: SAR + FBA + treatment plan + service order (annual). | 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:

- **97153:** Vaya's guidelines list this as "97153 96" — modifier 96 (habilitative) appears alongside the base code in its documentation table.
- **97154:** Vaya's guidelines list this as "97154 96" — modifier 96 (habilitative) appears alongside the base code.
- **97155:** Confirmed by two independent Vaya documents (Authorization Guidelines v2.0 and the May-2025 RB-BHT Guidance) and consistent with the May-2019 NC Medicaid Bulletin restriction that 97155 does not cover routine technician-supervision/fidelity checks.
- **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: Vaya Health — Standard Rate Schedule: Tailored Plan/Medicaid Direct (Non-Clinician), dated 8/1/2024 Effective 2024-07-01.

| 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 | — |
| 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:** 1-866-990-9712
- **Phone menu path:** General Provider Support Service Line is 1-866-990-9712. Code-specific Authorizations (behavioral health) route to 1-800-893-6246 ext. 1515; Provider Portal/IT technical assistance is ext. 1500.
- **Hours:** 7 a.m.–6 p.m., Monday–Saturday, including holidays
- **Portal:** [Vaya Provider Portal](https://providers.vayahealth.com/provider-portal/)

Questions to ask on a verification call:

- What is Vaya's payer ID for 270/271 real-time eligibility checks — only Office Ally's 13010 is confirmed; Vaya does not appear on pVerify or Availity's national lists?
- What are the per-code unit caps for 97152, 97153, 97154, 97156, and 97157 (97151's 32-units/6-months and 97155's 10% passthrough are already confirmed)?
- 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 Vaya 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://cms.officeally.com/OfficeAlly/Forms/EDI/VayaHealth_SmokyMtn_EDI_ENR_PKT.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)
- https://providers.vayahealth.com/wp-content/uploads/2024/07/Standard_Rate_Schedule_Tailored-Plan-Medicaid-Direct_Non-Clinician_20240801.pdf (accessed 2026-07-23; source document older than 18 months)
- https://providers.vayahealth.com/contact/ (accessed 2026-07-23)

## Common questions

### Does Vaya Health cover ABA therapy?

Yes — as a Tailored Plan, Vaya administers RB-BHT under CCP 8F, with service authorization requests reviewed by its UM team ((800) 893-6246 ext. 1513, UM@vayahealth.com).

### Does every Vaya ABA request need a full SAR?

No — 97151 assessment requests up to 32 units per 6 months and 97155 up to a 1-hour-per-10-hours ratio against direct intervention pass through on notification alone. Above either threshold, a complete SAR (service order, treatment plan, validated diagnosis) is required.

## Primary sources

1. [Vaya Health — Authorization Guidelines: Medicaid RB-BHT Services for ASD (v2.0, rev. 9/5/2025)](https://providers.vayahealth.com/wp-content/uploads/2025/09/Authorization_Guidelines_Medicaid_RB_BHT_ASD.pdf)
2. [Vaya Health — RB-BHT Guidance (v1.0, rev. 5/1/2025)](https://providers.vayahealth.com/wp-content/uploads/2025/05/RB_BHT_Guidance_20250522.pdf)
3. [Vaya Health — prior authorization page](https://providers.vayahealth.com/authorization-information/prior-authorization/)
4. [NC Medicaid — Clinical Coverage Policy 8F](https://medicaid.ncdhhs.gov/8f-research-based-behavioral-health-treatment-rb-bht-autism-spectrum-disorder-asd/open)
5. [Vaya Health — Provider Operations Manual v3.1 (3/5/2026)](https://providers.vayahealth.com/resources/vaya_provider_operations_manual_3-1_20260305/)
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. [NC Medicaid Standard Plan contract, Amendment 17(18) — "Rating Period" defined as July 1 to June 30](https://medicaid.ncdhhs.gov/contract-30-190029-dhb-prepaid-health-plan-services-amendment-1718/open)
8. [TRICARE — Using Other Health Insurance (updated 10/17/2025)](https://www.tricare.mil/Plans/OHI)
9. [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.