Alliance Health is one of NC's three Tailored Plans, and for ABA providers it stands out on two fronts: it publishes an actual rate schedule (the clearest public confirmation of the state fee-schedule floor in action), and its February 2026 RB-BHT guidance spelled out diagnostic-instrument and service-order requirements more explicitly than any other NC plan (that guidance has since been archived; the diagnostic list now to use is the rewritten CCP 8F's). Clinically it's straight CCP 8F — but its documentation bar is where referrals get screened out.
Diagnostic instruments: go by the state list. The rewritten CCP 8F (eff. 8/1/2026, subsection 3.2.4) requires a non-provisional ASD diagnosis made with BOSA, Tele-ASD-Peds, ADOS-2 or CARS2-ST/CARS2-HF (or later versions), and says services may not start on screening tools, educational determinations or informal clinical impressions alone. Alliance's February 2026 RB-BHT guidance, which predated the rewrite, named ADI-R, ADOS-2, CARS-2 and TELE-ASD-PEDS and rejected GARS, M-CHAT and SRS as standalone diagnoses, but Alliance has since archived that page (it returns 410 "Information Archived" as of September 27, 2026) and no replacement Alliance list was found — so treat a diagnosis resting on ADI-R alone as not meeting the state list. The same archived guidance was specific on the service order: signed by an MD, DO, or licensed psychologist, based on a behavioral/adaptive/functional assessment, dated on or before the service start, valid one year — and a bare "medical necessity statement" does not qualify. Alliance's current RB-BHT cover sheet, which must go with every prior authorization request, repeats the service-order elements (MD/DO/psychologist, under one year old, on or before the start of service, based on a behavioral, adaptive or functional assessment) but not the medical-necessity-statement wording. Screen referral packets against both requirements at intake; sending families back for a qualifying diagnostic evaluation mid-authorization is where NC pipelines stall.[7][5]
Alliance publishes its standard rate schedule outright — RB-BHT at the state fee-schedule levels, per 15-minute unit, effective 10/1/2025: 97151 $30.56, 97152 $61.73, 97153 $20.81, 97154 $11.37, 97155 $32.22, 97156 $23.70, 97157 $11.51 (noted as subject to LME/MCO funding). Authorization follows the 8F baseline — PA on everything, with authorization length tiered by intensity (180 calendar days at ≤16 hrs/week, 90 above) — and with the plan's fillable RB-BHT cover sheet accompanying service requests through Alliance UM. Alliance also participates as a Children & Families Specialty Plan network partner.[6][7][3]
Code set: like every NC Medicaid plan, this one pays RB-BHT only under the CPT codes in CCP 8F Attachment A, 97151–97157, in 15-minute units. 97158, 0362T and 0373T are not covered, and no HCPCS H-code (H0031, H0032, H2014, H2019) is an RB-BHT code. The plan publishes no different code list. 96112 (developmental testing) is likewise not an RB-BHT code; NC Medicaid’s billing guidance lists it among procedure codes shared by physical and behavioral health.[6][7][3]
Closed. Alliance lists research-based behavioral health treatment among the services "subject to the mandatory closed network," citing Senate Bill 257 (S.L. 2026-41): "each Prepaid Health Plan (PHP) will be required to develop and maintain a mandatory closed network" for these services and "may exclude providers from their closed networks." For providers: "Providers interested in delivering these services must go through Alliance's specific contracting and credentialing processes. These services are not available through our standard network participation agreements." Alliance points applicants to its current service needs list, and questions go to NetworkRelations@AllianceHealthPlan.org.[8][9]
Every applicant also has to be enrolled in NCTracks before applying to Alliance.[8][9]
North Carolina licenses the practice itself: “it shall be a violation of this Article for any individual not licensed under this Article to practice behavior analysis” (G.S. 90-746(a); a Class 2 misdemeanor under 90-746(b)), with exemptions for NC-licensed psychologists and for behavior technicians working under a licensed professional’s direction (G.S. 90-745). An analyst licensed elsewhere has two routes: a temporary license for one who “resides and practices behavior analysis in another state,” available “only if the behavior analysis services are to be delivered during a limited and defined period of service approved by the Board” (G.S. 90-740), and licensure by reciprocity for someone actively licensed in a state with comparable requirements that reciprocates with North Carolina (G.S. 90-741). Article 43 contains no telehealth exception, so plan on an NC license before treating a child located in North Carolina by video.[11][12][13][14]
For NC Medicaid the answer is now no for a new enrollee. Session Law 2026-1 added G.S. 108C-9(e): “Board Certified Behavior Analysts and Qualified Autism Services Practitioner Supervisors shall not be permitted to enroll in the North Carolina Medicaid program as out-of-state providers,” applying to enrollment applications submitted on or after the law took effect. NC Medicaid’s August 31, 2026 reminder restates it: all LQASPs and C-QPs, “including Board Certified Behavior Analysts and Board Certified Assistant Behavior Analysts, seeking to enroll in the NC Medicaid program must do so as an in-state provider,” effective August 2, 2026.[11][12][13][14]
Federal rules make the state Medicaid enrollment rule binding on the plan: the state “must screen and enroll, and periodically revalidate, all network providers” of Medicaid managed care plans (42 CFR 438.602(b)(1)). So a BCBA in Alliance Health’s network has to be enrolled with NC Medicaid as well.[11][12][13][14]
NC Medicaid’s rule binds the plans: CCP 8F (amended 8/1/2026) requires prior approval before RB-BHT services, says services provided without prior authorization “are not considered for payment or reimbursement except in the case of retroactive Medicaid eligibility,” and lists “services provided without prior authorization by the PHP” among the services Medicaid does not cover.[7][2]
Alliance’s Tailored Plan/PIHP manual (V.26, March 2026) says it “will review post-service requests for authorization of inpatient admissions or outpatient services only if, at the time of treatment, the member was not eligible and became eligible with Alliance Health retroactively, or, in cases of emergency treatment, the payer was not known at the time of service.” Its decision table gives retrospective requests 30 calendar days “unless a more restrictive requirement is issued by NC Medicaid or accrediting bodies.”[7][2]
NC Medicaid sets the floor for every Tailored Plan and LME/MCO, Alliance Health included. Its prompt-payment fact sheet gives Tailored Plans a 365-day timely filing window from July 1, 2024. NC Medicaid Direct claims the LME/MCOs process also moved from 90 to 365 days on July 1, 2024. The window covers the original claim and any corrected claim. State-funded services must be filed within 90 calendar days.[15][2][3][1]
Within 18 calendar days of receiving a medical claim the plan must say whether it is clean or pend it for more information. It must pay or deny a clean claim within 30 days, and deny the claim if requested information has not arrived within 90 days. Late payment carries 18% annual interest.[15][2][3][1]
Alliance’s own manual (V.26, 2026) uses the same 365-day Medicaid and 90-day State windows, but it is stricter on corrections: “Providers may submit a replacement claim for a previously paid claim within 180 calendar days post service date. Replacement claims submitted past 180 calendar days are denied for exceeding the timely filing requirements.” That conflicts with the state fact sheet’s rule that the 365 days covers corrected claims, so file replacements inside 180 days, or ask Alliance claims (Claims@AllianceHealthPlan.org) which limit it applies. When another insurer pays after Alliance has, submit a replacement claim with the updated COB within 30 calendar days of that payment. Claims rejected for missing or invalid provider or member data do not count as received. Payment follows Alliance’s published checkwrite schedule. Accounts Payable emails a notice of each upcoming EFT deposit, and the manual’s example is a Friday email with the deposit the following Tuesday.[15][2][3][1]
EVV does not apply to RB-BHT: NC Medicaid’s billing guidance lists the services “subject to EVV for Managed Care” as Personal Care, Home Health, Innovations Waiver, TBI and 1915(i) services (§3.52).[15][2][3][1]
Taxonomy: the plan must “validate the taxonomy code submitted on the claim” against the provider’s NC Medicaid enrollment record and “price claims based on the taxonomy code submitted on the claim” (billing guidance §3.22), so bill the taxonomy you are enrolled under in NCTracks. Alliance’s manual: “Providers are required to submit claims with the correct taxonomy code consistent with the provider’s specialty and services being rendered … Alliance Health may reject the claim if the taxonomy code is incorrect or omitted,” and billing/rendering NPI and taxonomy must match the NCTracks enrollment.[15][2][3][1]
Referring or ordering NPI: not required on an RB-BHT claim. NC Medicaid’s OPR guidance lists the claim types that need an ordering NPI (home infusion, private duty nursing, labs, IDTF, CAP, radiology, DME, LEA) or a referring NPI (home infusion, specialized therapy, hospice, home health, PDN, dialysis, CAP, LEA), and RB-BHT is not on either list. The physician or psychologist who signs the service order must still be enrolled in NC Medicaid (42 CFR 455.410).[15][2][3][1]
The questions that decide whether a family can start with Alliance Health (NC Tailored Plan), and what they have to bring. Each maps onto something intake should ask on the first call.
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.[7][5]
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.[7][5]
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.[7][5]
Follows the NC Medicaid rule: the non-provisional ASD diagnosis must be made with BOSA, Tele-ASD-Peds, ADOS-2 or CARS2-ST/CARS2-HF (or later versions) — ADI-R is not on the state list — and services may not start on screening tools, educational determinations or informal clinical impressions alone. The authorization 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). Alliance's February 2026 guidance, which named ADI-R, ADOS-2, CARS-2 and TELE-ASD-PEDS and rejected GARS, M-CHAT and SRS as standalone diagnoses, predated the rewrite and has been archived (the page returns 410 "Information Archived" as of 9/27/2026); no current Alliance-specific instrument list was found.[7][5]
Alliance checks the state service-order rule on its RB-BHT cover sheet, which every prior authorization request must include. The service order must be completed, signed and dated by a licensed MD, DO or psychologist, be less than one year old, be in place on or before the day services start, and be based on a behavioral, adaptive or functional assessment. The cover sheet has a checkbox confirming the order's text "includes evidence the Service Order was based on a Behavioral, Adaptive, or Functional Assessment." (CCP 8F §3.2.6 sets the same elements.)[7][5][10]
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. NC Medicaid’s billing guidance binds the plan to the same edit: “Claims submitted with Modifier GT (Telehealth) for 97152 - 97154 are not reimbursable and should be denied” (v36 §3.54.1). Telehealth claims carry the provider’s usual place-of-service code (8F Attachment A), and 8F does not require the telehealth modality to be named on the authorization.[7][5][3]
Alliance’s provider manual (V.26, March 2026) sets standard authorization decisions at 14 calendar days and expedited at "72 hours of the request", each extendable by 14 calendar days, with retrospective reviews at 30 calendar days; "All timelines in this document refer to calendar days unless otherwise specified," and "Incomplete forms are not processed and will be returned to the requesting provider." 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 this manual edition, so expect 7 and confirm with Alliance UM. Continuing requests are due "on or before the last day of the previously authorized date of service"; CCP 8F requires the RB-BHT reauth before the current authorization expires.[2][17][18][7]
"Alliance Health is the payer of last resort. Providers are required to collect all third-party funds prior to submitting claims." Upload the other insurer’s RA/EOB into ACS with the claim (a $0-paid third-party claim needs the denial documentation), and "Only the remaining amount of the consumer responsibility under their insurance policy is reimbursable by Alliance Health when Medicaid is secondary coverage." If the other insurer pays later, send a replacement claim within 30 calendar days. Pay-and-chase: "EPSDT claims are paid by Medicaid as the primary payer; Alliance Health will seek recovery from any liable third party." State funds pay after Medicaid for state-funded services. 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.[2][7][19][20]
Coverage decides whether Alliance Health (NC Tailored Plan) pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
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. Neither CCP 8F nor the plan’s own manual caps how many paraprofessionals one LQASP may supervise; the limits are the per-beneficiary 10% floor and 10–20% band.[7][5]
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. Follows the NC Medicaid rule here too. ABA alongside speech, occupational or physical therapy: Policy 8F (amended 8/1/2026) §4.2.1(n) does not cover "non-RB-BHT Medicaid services billed at the same time as RB-BHT service (as reflected in the session note …). Same-day delivery is allowable." So a speech, OT or PT visit may fall on the same day as ABA, but not on the same clock time as a billed RB-BHT session — and the session note, which must record session time in and out (§5.5.1), is what shows the two did not overlap. §4.1(c) separately excludes any service that duplicates another provider's service.[7][5]
Two different ceilings. Per day, a claim edit: NC Medicaid applies the CMS Medicaid National Correct Coding Initiative to professional claims, including Medically Unlikely Edits — units-of-service edits that define for each CPT or HCPCS code "the number of units of service that is unlikely to be correct" — and its billing guidance tells every health plan to apply NCCI and MUE edits as well (§3.6.2). Alliance’s provider manual (V.26, March 2026) confirms its claim edits identify "medically unlikely procedures, procedure to procedure exclusions, duplicate claims, frequency limits". The public CMS Medicaid NCCI practitioner MUE table for dates of service 10/1–12/31/2026 sets these maxima per beneficiary per date of service: 97151 32 units, 97152 16, 97153 32 (8 hours), 97154 18, 97155 24, 97156 16, 97157 16, 97158 16, 0362T 16 and 0373T 32. Units above the MUE on one date of service deny as a claim edit whatever the authorization allows; the authorization, not the MUE, is the real weekly limit. Per authorization period, the NC Medicaid rule (CCP 8F sets no per-day cap of its own): 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.[7][3][4][2][5]
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.[7][5]
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.[7][5]
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.[7][5]
Yes — as a Tailored Plan, Alliance administers RB-BHT under CCP 8F, paying the state fee-schedule rates (97153 at $20.81/15-min, 97155 at $32.22/15-min, effective 10/1/2025).
Go by the state list in CCP 8F (eff. 8/1/2026): BOSA, Tele-ASD-Peds, ADOS-2 or CARS2-ST/CARS2-HF. Alliance's older February 2026 guidance also named ADI-R, but that guidance has been archived and ADI-R is not on the state list, so do not rely on ADI-R alone. Screening tools such as M-CHAT cannot start services on their own.
Completed, signed and dated by a licensed MD, DO or psychologist; under one year old; in place on or before the first day of service; and visibly based on a behavioral, adaptive or functional assessment. Alliance's RB-BHT cover sheet asks you to confirm each of these, and CCP 8F §3.2.6 sets the same rule.
Closed. RB-BHT is on Alliance's mandatory closed-network list under S.L. 2026-41, and Alliance says providers who want to deliver it must go through its specific contracting and credentialing process, not a standard participation agreement. Check its current service needs list and email NetworkRelations@AllianceHealthPlan.org.
Alliance Health applies CCP 8F, which does not say an authorization transfers. CCP 8F treats needing "a different RB-BHT provider agency" as a transition or discharge reason, requires the Treatment Plan to be reviewed on a change in service provider, and will not pay two providers for duplicate services. Expect the new agency to submit its own request, and confirm with Alliance Health utilization management.
North Carolina requires an NC license to practice behavior analysis (G.S. 90-746), with no telehealth exception; temporary and reciprocity licenses exist (G.S. 90-740, 90-741). NC Medicaid no longer enrolls BCBAs as out-of-state providers (G.S. 108C-9(e)), and plan network providers must be enrolled with the state (42 CFR 438.602(b)(1)).
Only if the member became eligible with Alliance retroactively (or for emergency treatment when the payer was unknown); Alliance decides retrospective requests within 30 calendar days.
365 days from the date of service for Tailored Plan and NC Medicaid Direct claims since July 1, 2024, corrected claims included, under NC Medicaid’s rule for LME/MCOs. State-funded services are 90 days. Clean claims must be paid or denied within 30 days.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 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.
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