Healthy Blue — the Anthem/Elevance Standard Plan — administers NC Medicaid's RB-BHT benefit by adopting the state Clinical Coverage Policies wholesale: no Healthy-Blue-specific ABA clinical criteria exist. That makes this a mechanics guide: where requests go, which fax lines answer, and one structural wrinkle — Blue Cross NC also operates the separate Children & Families Specialty Plan, so foster-care-involved children will show up under a different plan than standard Healthy Blue.
The provider manual lists RB-BHT among covered behavioral-health services and adopts NC's Clinical Coverage Policies — so the whole clinical picture (PA on everything including assessment, the tiered 180/90-day authorization cadence, and treatment-plan reviews at each goal's target date and on any change in needs, provider or services — the 8/1/2026 rewrite dropped the old annual-rewrite rule) is the CCP 8F baseline covered in the state guide. Submissions run through Availity Essentials' Interactive Care Reviewer; behavioral-health authorization fax lines are (844) 429-9636 for outpatient and (844) 439-3574 for inpatient, with provider services at (844) 594-5072. Use the plan's Precertification Lookup Tool to confirm code-level requirements before submitting.[7][4][6][2]
One detail from the manual: RB-BHT is explicitly exempt from the plan's standard network time/distance standards. That is a network-adequacy rule, not an open door — since July 7, 2026, S.L. 2026-41 §9E.22 requires every NC Medicaid health plan to maintain a closed network for RB-BHT and allows it to exclude providers, so confirm with Healthy Blue provider contracting that it is taking new RB-BHT providers before planning an expansion into new counties.[7][4][6][2]
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.[7][4][6][2]
Since December 1, 2025, child-welfare-involved members are auto-enrolled in the statewide Children & Families Specialty Plan ("Healthy Blue Care Together"), also operated by Blue Cross NC — a separate plan from standard Healthy Blue with its own member IDs. For intake, this means a foster or kinship placement family saying "we have Healthy Blue" needs one more verification question before you pick the submission path.
Closed by statute for RB-BHT. Session Law 2026-41 §9E.22 (approved July 7, 2026) amended G.S. 108D-22 so that "each PHP shall develop and maintain a closed network, and may exclude providers from that closed network" for peer support services and research-based behavioral health treatment services. That binds Healthy Blue as an NC Medicaid Standard Plan. Being enrolled in NCTracks therefore no longer guarantees a contract.[7][14]
As of October 1, 2026 no Healthy Blue notice on how it is applying the closed network was found. The Tailored Plans that have published one (Trillium, Vaya, Partners, Alliance) keep current contracted providers and review new applicants against network need. Ask Healthy Blue provider contracting whether it is accepting new RB-BHT providers in your counties before you plan on it.[7][14]
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.[8][9][10][11]
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.[8][9][10][11]
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 Healthy Blue’s network has to be enrolled with NC Medicaid as well.[8][9][10][11]
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.[6][4]
Healthy Blue’s NC provider manual sets a decision clock for “Retrospective review requests: within 30 days of request,” but we have not verified which circumstances Healthy Blue accepts for an RB-BHT retrospective review; ask its UM team before treating without an approval.[6][4]
NC Medicaid sets these for every Standard Plan, Healthy Blue included. Its prompt-payment fact sheet gives Standard Plans a 365-day timely filing window (in effect since July 1, 2023), covering the original claim and any corrected claim. A late claim is not invalidated if filing on time was not reasonably possible, as long as it is filed as soon as possible and within a year of the original deadline.[12][4][2][1]
Within 18 calendar days of receiving a medical claim the plan must say whether it is clean or pend it and ask for what is missing. It must pay or deny a clean claim within 30 days, and deny a claim when requested information has not arrived within 90 days. Late payment carries 18% annual interest, without the provider having to ask. Check your own contract too, since a provider agreement can set its own terms.[12][4][2][1]
Healthy Blue’s own manual matches that window: submit claims “within 365 calendar days from the date of service.” For other insurance, “submit the claim within 365 calendar days from the third-party payer,” and the clock starts “on the date of the primary carrier’s Explanation of Benefits.” Corrected claims go in electronically with frequency code 7 (replacement of prior claim). Healthy Blue pays or denies clean claims “at lesser of 30 calendar days of receipt of the claim or the first scheduled provider reimbursement cycle following adjudication.” Each Explanation of Payment covers the claims adjudicated in the previous cycle. The manual does not publish the cycle day or a submission cutoff.[12][4][2][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).[12][4][2][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. Healthy Blue’s manual lists the “Taxonomy of billing provider, attending and rendering provider when submitted” among required claim data and verifies provider data “against state reference data.”[12][4][2][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).[12][4][2][1]
Disputes and appeals: for a zero or partial payment, file with the Healthy Blue Payment Dispute Unit (P.O. Box 61599, Virginia Beach, VA 23466). “We must receive your dispute within 60 calendar days from the date of the EOP”; Healthy Blue decides within 30 business days, and a Level II review must reach it within 30 calendar days of the Level I letter. Adverse benefit determinations, such as an authorization denial, go to provider appeals: within 90 calendar days of the notice, acknowledged in 5 calendar days and resolved in 30. A second-level appeal is due within 30 calendar days of the first resolution letter. The internal process must be exhausted before any other route.[12][4][2][1]
The questions that decide whether a family can start with Healthy Blue (NC), 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.[6]
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.[6]
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.[6]
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).[6]
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 an assessment and treatment plan, valid one year. Healthy Blue adopts the state Clinical Coverage Policies wholesale and publishes no ABA-specific referral rule of its own; code-level requirements are confirmed in the plan’s Precertification Lookup Tool and requests go through Availity Essentials’ Interactive Care Reviewer.[6][4]
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.[6][2]
Healthy Blue’s manual (Blue Cross NC) sets behavioral health turnarounds tighter than the federal floor: routine initial requests are decided "within two business days of receipt of all necessary information but no later than 7 days from the request for services", and routine concurrent (continuing) requests "within one business day of obtaining all necessary information but no later than 7 days from the request for services." Expedited decisions come "no later than 72 hours after receipt of the request for service", and requests marked expedited that do not meet the federal urgency standard are downgraded to standard. RB-BHT is on the PA list. The manual gives no reauthorization lead time; CCP 8F requires the reauth before the current authorization expires (every 180 days at ≤16 hrs/week, every 90 above).[4][6]
Healthy Blue pays last: submit to the primary insurer first, then bill Healthy Blue the balance. It is the one NC plan that answers the secondary-PA question in writing: "Blue Cross NC does not require prior authorization (PA) when the member has OHI. However, a PA will be required if Healthy Blue becomes the primary payer for the service(s) rendered" — so if the commercial plan denies or exhausts ABA, get Healthy Blue’s PA before Healthy Blue becomes primary. Pay-and-chase (paid first, recovered later) is limited to prenatal care, preventive pediatric services "including Early and Periodic Screening, Diagnosis and Treatment (EPSDT) and well-baby screenings", and child-support cases; everything else is cost-avoided. Check other coverage in Availity, not NCTracks. Under federal rules TRICARE pays before Medicaid and CHAMPVA pays first when the child is also Medicaid-eligible.[4][15][16]
Coverage decides whether Healthy Blue (NC) 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.[6]
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.[6]
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). Healthy Blue’s provider manual says the same: NC Medicaid must "incorporate NCCI methodologies into their claims processing systems," and MUEs are "units of service edits for practitioners". 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.[6][2][3][4]
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.[6]
Follows the NC Medicaid rule on covered settings (clinic, home, school, community, individually justified in the treatment plan). One plan-level note that matters for geography rather than the claim: the Healthy Blue provider manual exempts RB-BHT from the plan’s standard network time and distance standards.[6][4]
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.[6]
Yes — Healthy Blue administers NC Medicaid's RB-BHT benefit by adopting Clinical Coverage Policy 8F: PA on all services including assessment, authorization cycles tiered by intensity (180 calendar days at ≤16 hrs/week, 90 days above), LQASP treatment-plan reviews.
Via Availity Essentials' Interactive Care Reviewer, or fax (844) 429-9636 for outpatient behavioral health. Check the Precertification Lookup Tool for code-level requirements first.
The separate Children & Families Specialty Plan (launched December 2025) for child-welfare-involved members, also run by Blue Cross NC. Foster families' "Healthy Blue" cards may actually be CFSP — verify before submitting.
For RB-BHT, NC law has required a closed network since July 7, 2026 (S.L. 2026-41 §9E.22), so Healthy Blue may decline new providers. It had published no notice on how it is applying this as of October 1, 2026; ask its provider contracting team directly.
Healthy Blue 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, bases prior approval on the Treatment Plan submitted with the request, and will not pay two providers for duplicate services. Expect the new agency to submit its own request, and confirm with Healthy Blue 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)).
Plan on no. CCP 8F excludes services provided without the plan’s prior authorization except for retroactive Medicaid eligibility. Healthy Blue decides retrospective review requests within 30 days; confirm the qualifying circumstances with its UM team.
365 days from the date of service, the window NC Medicaid requires of every Standard Plan since July 1, 2023, corrected claims included. Clean claims must be paid or denied within 30 days. Check your Healthy Blue contract for any agreed terms.
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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