---
title: "WellCare of North Carolina: merged into Carolina Complete Health (4/1/2026)."
url: "https://carelu.com/payers/wellcare-north-carolina"
markdown_url: "https://carelu.com/payers/wellcare-north-carolina.md"
state: NC (North Carolina)
payer: WellCare of North Carolina
kind: Medicaid managed care plan (MCO)
parent_program: North Carolina Medicaid
description: "WellCare of North Carolina merged into Carolina Complete Health effective April 1, 2026, and is no longer a standalone NC Medicaid Standard Plan. What changed, where WellCare members go now, and the plan's prior RB-BHT policy (WNC.CP.109) for reference."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# WellCare of North Carolina: merged into Carolina Complete Health (4/1/2026).

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

> MERGED into Carolina Complete Health effective 4/1/2026 — no longer a standalone Standard Plan.

WellCare of North Carolina merged into Carolina Complete Health effective April 1, 2026 — it no longer exists as a standalone NC Medicaid Standard Plan. Members who previously carried a WellCare of NC card are now served by Carolina Complete Health; see that guide for current authorization mechanics and the plan's (now statewide) footprint. This page is kept for reference and for anyone still searching by the WellCare name — the clinical policy history below (WNC.CP.109, a near-verbatim restatement of CCP 8F) reflects how the plan operated before the merger.

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:** Not published / unverified. Verify via: WellCare NC Medicaid Behavioral Health Authorization List / Authorization Lookup Tool. WNC.CP.109 deliberately lists no PA'd codes and delegates code-level requirements to the lookup tool, which is not publicly retrievable. (Historical plan — WellCare NC merged into Carolina Complete Health 4/1/2026.) [3][2]
- **Prior auth for treatment**: Required — WNC.CP.109 restates 8F: LQASP plan, review ≥ every 6 months [2][3]
- **Autism diagnosis required?**: Yes — ASD via a validated diagnostic tool; under-3s may start on a provisional diagnosis [2][3]

## At a glance

- **Plan status:** MERGED into Carolina Complete Health effective April 1, 2026 — go to the Carolina Complete Health guide
- **Plan type (historical):** NC Medicaid Standard Plan (Centene)
- **Clinical rules (historical):** WNC.CP.109 — restated CCP 8F; state rules took precedence
- **Prior auth (historical):** Code-level PA via the Authorization Lookup Tool + BH auth list
- **Telehealth (historical):** Governed by separate policy WNC.CP.193
- **Rates (historical):** ≥100% of the NC Medicaid fee schedule (state floor)

## How WellCare administers RB-BHT

WNC.CP.109 mirrors 8F's criteria — under-21 coverage via EPSDT, a validated diagnostic tool, provisional diagnosis under age three with definitive diagnosis within six months, LQASP treatment plans reviewed at least every six months — and defers wholesale to CCP 8F Section 6.0 on provider qualifications. Rather than listing PA'd codes in the policy, WellCare delegates code-level requirements to its Authorization Lookup Tool and Medicaid Behavioral Health Authorization List, so check your specific codes there before each submission cycle. Telehealth for RB-BHT is governed by a separate policy (WNC.CP.193), with telephonic parent training allowed only for documented caregiver health or access barriers — and the state's finalized CCP 8F, effective August 1, 2026, now tightens ABA telehealth further statewide: telehealth is removed entirely for 97152, 97153, and 97154, while 97155 is capped at 50% of billing per beneficiary per 180 days (historical note: WellCare of NC merged into Carolina Complete Health effective April 1, 2026, so this policy is kept for reference only). [2][3][1]

## Intake gates

The questions that decide whether a family can start with WellCare of North Carolina, 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. [3][2]
- **Diagnosis recency**: Historical. WNC.CP.109 mirrored the state rule — a validated diagnostic tool, and a provisional diagnosis under age three with a definitive diagnosis within six months. WellCare of North Carolina merged into Carolina Complete Health effective April 1, 2026, so the operative rule for these members is now the state rule as administered by Carolina Complete Health. [3][2][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. [3][2]
- **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). [3][2]
- **Referral required?**: Follows the NC Medicaid rule: a service order signed and dated by a Licensed MD, DO or Licensed Psychologist, in place on or before the first date of service, based on a behavioral/adaptive/functional assessment and treatment plan, valid one year and re-ordered annually. 97151 and 97152 need no service order for prior approval; 97153–97157 do. [3][2]
- **Telehealth**: Historical. WellCare governed RB-BHT telehealth through a separate policy, WNC.CP.193, allowing telephonic parent training only for documented caregiver health or access barriers. The state’s finalized CCP 8F (eff. 8/1/2026) now controls statewide: telehealth removed entirely for 97152, 97153 and 97154, 97155 capped at 50% of billing per beneficiary per 180 days, 97151 telehealth eligible with clinical justification, and 97156/97157 keeping the KX telephonic caregiver-barrier exception. WellCare of NC merged into Carolina Complete Health on April 1, 2026. [3][2][2][1]
- **Prior-auth decision time**: WellCare of NC merged into Carolina Complete Health on April 1, 2026, and CCH’s rules govern dates of service from then on (standard 14 calendar days per its manual, which dates the 7-day change to January 1, 2027, against a federal 7-calendar-day ceiling that reaches NC plans from July 1, 2026; expedited 72 hours). For pre-merger dates of service, WellCare’s last manual said standard pre-service decisions "will not exceed 14 (14) calendar days" with a 14-day extension, expedited 72 hours, urgent concurrent 24 hours, and post-service 30 calendar days. CCP 8F requires the reauth before the current authorization expires; active WellCare authorizations transferred to CCH. [1][4][5][6][3]
- **Other insurance (who pays first)**: For dates of service from April 1, 2026, bill Carolina Complete Health, which pays last: the other insurer first, then CCH with its EOB/EOP or rejection letter, within 365 calendar days of the primary EOB/RA date. For pre-merger claims, WellCare’s manual required "Any balance due after receipt of payment from the primary payer" to be submitted "with a copy of the primary payer's explanation of payment (EOP)", within 90 days of the primary EOB date, paid on lesser-of logic. Neither manual says whether the plan’s own PA is needed when it pays second; CCP 8F requires prior approval before rendering RB-BHT with no exception for other insurance. Under federal rules TRICARE pays before Medicaid and CHAMPVA pays first when the child is also Medicaid-eligible. [1][7][5][3][8][9]

## Delivery and billing rules

Coverage decides whether WellCare of North Carolina 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. [3][2]
- **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. [3][2]
- **Daily limits / MUEs**: 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][2]
- **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. [3][2]
- **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. [3][2]
- **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. [3][2]

## What intake should collect for WellCare of North Carolina

- **Redirect to Carolina Complete Health:** WellCare of NC no longer exists as a standalone plan — route WellCare-branded inquiries to the Carolina Complete Health guide and workflow.
- **Code-level PA check (historical):** The Authorization Lookup Tool was the source of truth for WellCare NC — no longer applicable post-merger.
- **ASD diagnosis + validated tool:** Per 8F; provisional-dx path documented for under-3s. This requirement carries over to Carolina Complete Health.

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

## Verification of benefits (VOB) data

How WellCare of North Carolina ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00734 — pVerify's own March 2026 entry (00734 "WELLCARE OF NORTH CAROLINA") is flagged Eligibility=No, Claim Status=No — consistent with the plan being sunset into Carolina Complete Health. Do not route new eligibility checks through this ID.
- **Behavioral health administrator:** none
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes (97151, historical — pre-4/1/2026 merger; route current inquiries to carolina-complete-health) | Required — per the CCP 8F baseline WNC.CP.109 restates; code-level PA requirements were delegated to WellCare's own Authorization Lookup Tool / Medicaid Behavioral Health Authorization List (not independently re-verified this pass). | Not published in WNC.CP.109 per Not published in WNC.CP.109 | usual place of service — no telehealth-specific POS number published by WNC.CP.109 | Yes — modifier GT (interactive audio-visual). WNC.CP.109 states telephonic (audio-only) delivery is not billable for this code. | GT |
| 97152 | Yes (97152, historical — pre-4/1/2026 merger; route current inquiries to carolina-complete-health) | Required — per the CCP 8F baseline WNC.CP.109 restates; code-level PA requirements were delegated to WellCare's own Authorization Lookup Tool / Medicaid Behavioral Health Authorization List (not independently re-verified this pass). | Not published in WNC.CP.109 per Not published in WNC.CP.109 | usual place of service — no telehealth-specific POS number published by WNC.CP.109 | Yes — modifier GT (interactive audio-visual). WNC.CP.109 states telephonic (audio-only) delivery is not billable for this code. | GT |
| 97153 | Yes (97153, historical — pre-4/1/2026 merger; route current inquiries to carolina-complete-health) | Required — per the CCP 8F baseline WNC.CP.109 restates; code-level PA requirements were delegated to WellCare's own Authorization Lookup Tool / Medicaid Behavioral Health Authorization List (not independently re-verified this pass). | Not published in WNC.CP.109 per Not published in WNC.CP.109 | usual place of service — no telehealth-specific POS number published by WNC.CP.109 | Yes — modifier GT (interactive audio-visual). WNC.CP.109 states telephonic (audio-only) delivery is not billable for this code. | GT |
| 97154 | Yes (97154, historical — pre-4/1/2026 merger; route current inquiries to carolina-complete-health) | Required — per the CCP 8F baseline WNC.CP.109 restates; code-level PA requirements were delegated to WellCare's own Authorization Lookup Tool / Medicaid Behavioral Health Authorization List (not independently re-verified this pass). | Not published in WNC.CP.109 per Not published in WNC.CP.109 | usual place of service — no telehealth-specific POS number published by WNC.CP.109 | Yes — modifier GT (interactive audio-visual). WNC.CP.109 states telephonic (audio-only) delivery is not billable for this code. | GT |
| 97155 | Yes (97155, historical — pre-4/1/2026 merger; route current inquiries to carolina-complete-health) | Required — per the CCP 8F baseline WNC.CP.109 restates; code-level PA requirements were delegated to WellCare's own Authorization Lookup Tool / Medicaid Behavioral Health Authorization List (not independently re-verified this pass). | Not published in WNC.CP.109 per Not published in WNC.CP.109 | usual place of service — no telehealth-specific POS number published by WNC.CP.109 | Yes — modifier GT (interactive audio-visual). WNC.CP.109 states telephonic (audio-only) delivery is not billable for this code. | GT |
| 97156 | Yes (97156, historical — pre-4/1/2026 merger; route current inquiries to carolina-complete-health) | Required — per the CCP 8F baseline WNC.CP.109 restates; code-level PA requirements were delegated to WellCare's own Authorization Lookup Tool / Medicaid Behavioral Health Authorization List (not independently re-verified this pass). | Not published in WNC.CP.109 per Not published in WNC.CP.109 | usual place of service — no telehealth-specific POS number published by WNC.CP.109 | Yes — modifier GT (interactive audio-visual); ALSO telephonic-billable with modifier KX (audio-only) if the criteria in WNC.CP.109 §I.E./V.D. are met. | GT, KX (conditional, audio-only) |
| 97157 | Yes (97157, historical — pre-4/1/2026 merger; route current inquiries to carolina-complete-health) | Required — per the CCP 8F baseline WNC.CP.109 restates; code-level PA requirements were delegated to WellCare's own Authorization Lookup Tool / Medicaid Behavioral Health Authorization List (not independently re-verified this pass). | Not published in WNC.CP.109 per Not published in WNC.CP.109 | usual place of service — no telehealth-specific POS number published by WNC.CP.109 | Yes — modifier GT (interactive audio-visual); ALSO telephonic-billable with modifier KX (audio-only) if the criteria in WNC.CP.109 §I.E./V.D. are met. | GT, KX (conditional, audio-only) |
| 97158 | No — 97158 is not in CCP 8F Attachment A's billing-code table (97151-97157 only) or the restored NC Medicaid RB-BHT fee schedule | N/A — code not covered under NC Medicaid RB-BHT | N/A per N/A | — | N/A | — |
| 0362T | No — 0362T is not in CCP 8F Attachment A's billing-code table (97151-97157 only) or the restored NC Medicaid RB-BHT fee schedule | N/A — code not covered under NC Medicaid RB-BHT | N/A per N/A | — | N/A | — |
| 0373T | No — 0373T is not in CCP 8F Attachment A's billing-code table (97151-97157 only) or the restored NC Medicaid RB-BHT fee schedule | N/A — code not covered under NC Medicaid RB-BHT | N/A per N/A | — | N/A | — |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157:** Historical/reference only — WellCare of NC merged into Carolina Complete Health effective 4/1/2026. WNC.CP.109 was still live and unchanged as of the access date but may be withdrawn without notice; Carolina Complete Health's own clinical-policy index does not carry an equivalent CCH-branded successor, pointing to state 8F instead. Route current inquiries to the carolina-complete-health guide.
- **97158, 0362T, 0373T:** Confirmed absent from both the current, finalized CCP 8F (Amended Date: August 1, 2026, rewritten and published this cycle) and the fee schedule restored 2026-01-05 — NC Medicaid's RB-BHT code set does not include this code, unlike some other states' ABA fee schedules. Unchanged by the 8/1/2026 rewrite.

### Medicaid rates

Source: NC Medicaid RB-BHT fee schedule — the mandatory reimbursement floor Standard Plans had to meet pre-merger. Historical reference only; WellCare of NC merged into Carolina Complete Health effective 4/1/2026 — see carolina-complete-health for current rates/routing. 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 | — |

### Contacts

- **Provider services phone:** 1-833-552-3876
- **Hours:** Monday–Saturday, 7 a.m.–6 p.m. — this is Carolina Complete Health's provider-services line, the successor plan post-merger; WellCare of North Carolina no longer operates a standalone provider-services line under its own name (a "1-833-925-2861" number found on marketplace.wellcarenc.com this pass was confirmed to belong to WellCare's separate ACA Marketplace/Ambetter product, not this Medicaid Standard Plan, and was discarded rather than used).
- **Portal:** [Carolina Complete Health Provider Portal (successor to WellCare of NC, effective 4/1/2026)](https://provider.carolinacompletehealth.com)

Questions to ask on a verification call:

- For legacy WellCare-of-NC members, do RB-BHT eligibility and prior-authorization calls now route entirely through Carolina Complete Health's provider-services line?
- Which payer ID should I use for eligibility checks post-merger — Carolina Complete Health's 68069, or a legacy WellCare-specific code?
- What were the unit caps and cap periods for 97151-97157 under WNC.CP.109, and do they still apply post-merger?
- Is there a copay or coinsurance for RB-BHT, and if so is it per-visit or per-day?

### VOB data sources

- https://marketplace.wellcarenc.com (accessed 2026-07-23)
- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://business.optum.com/content/dam/optum4/business/open_source/practice-management/real-time-eligibility-payer-list.pdf (accessed 2026-07-23)
- https://network.carolinacompletehealth.com/merger.html (accessed 2026-07-23)
- https://medicaid.ncdhhs.gov/providers/provider-playbook-medicaid-managed-care/trending-topics/wellcare-north-carolina-and-carolina-complete-health-merge-april-1-2026 (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://www.policies-wellcare.com/content/dam/centene/wellcare/nc/policies/clinical-policies/WNC.CP.109.pdf (accessed 2026-07-23)
- https://medicaid.ncdhhs.gov/8f-research-based-behavioral-health-treatment-rb-bht-autism-spectrum-disorder-asd/open (accessed 2026-09-01)
- https://medicaid.ncdhhs.gov/blog/2025/12/19/medicaid-rate-reduction-reversal-update (accessed 2026-07-23)
- https://www.alliancehealthplan.org/document-library/97251 (accessed 2026-07-23)
- https://network.carolinacompletehealth.com/resources/behavioral-health.html (accessed 2026-07-23)

## Common questions

### Does WellCare of North Carolina still exist?

No — WellCare of North Carolina merged into Carolina Complete Health effective April 1, 2026, and is no longer a standalone NC Medicaid Standard Plan. Members and providers should use the Carolina Complete Health guide going forward.

### What happened to WellCare NC members after the merger?

They are now served by Carolina Complete Health, which expanded from its prior regional footprint to a statewide Standard Plan as part of the merger.

## Primary sources

1. [NC Medicaid — WellCare NC and Carolina Complete Health merge April 1, 2026 (Provider Playbook)](https://medicaid.ncdhhs.gov/providers/provider-playbook-medicaid-managed-care/trending-topics/wellcare-north-carolina-and-carolina-complete-health-merge-april-1-2026)
2. [WellCare NC — WNC.CP.109 RB-BHT clinical policy (historical)](https://www.policies-wellcare.com/content/dam/centene/wellcare/nc/policies/clinical-policies/WNC.CP.109.pdf)
3. [NC Medicaid — Clinical Coverage Policy 8F](https://medicaid.ncdhhs.gov/8f-research-based-behavioral-health-treatment-rb-bht-autism-spectrum-disorder-asd/open)
4. [Carolina Complete Health — Provider Manual 2026 (last updated 6/29/2026, state approved)](https://network.carolinacompletehealth.com/content/dam/centene/carolinacompletehealth/pdfs/CCHE_PRV15_Provider_Manual_2026.pdf)
5. [WellCare of North Carolina — 2025–2026 NC Medicaid Provider Manual (eff. 1/22/2026, pre-merger)](https://www.wellcarenc.com/content/dam/centene/wellcare/nc/pdfs/providers/NC_Medicaid_Provider_Manual_03_2026_R.pdf)
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. [Carolina Complete Health — Provider Billing Manual (last updated 7/14/2026)](https://network.carolinacompletehealth.com/content/dam/centene/carolinacompletehealth/pdfs/CCH-Current-Provider-Billing-Manual.pdf)
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.