---
title: "MedCost ABA coverage in North Carolina: the intake guide."
url: "https://carelu.com/payers/medcost"
markdown_url: "https://carelu.com/payers/medcost.md"
state: NC (North Carolina)
payer: MedCost Benefit Services
kind: Commercial insurance
description: "How ABA works on a MedCost card in North Carolina — a self-funded plan administrator and leased network, where the employer plan document sets the benefit, the ID card shows the precertification program, and the N.C.G.S. § 58-3-192 mandate may not reach the plan."
last_reviewed: September 2026
vob_data_updated: 2026-09-27
---

# MedCost ABA coverage in North Carolina: the intake guide.

_Payer Guide · MedCost · North Carolina · Last updated September 2026 · 12 primary sources_

> Carolinas self-funded plan administrator and network. The ID card shows whether precert applies; ABA codes 97153–97158 are on its outpatient-review list.

MedCost is a Carolinas benefits company with two businesses that both show up on ID cards: MedCost Benefit Services administers self-funded employer health plans (it says it serves more than 600 employers across the Carolinas and Virginia, pitches itself to self-funded companies with 50 or more employees, and sells a level-funded product to smaller employers), and the MedCost Network is a provider network that other payers lease. So the first intake question is who the payer is. The second is the employer group, because on a self-funded plan the employer's plan document, not a MedCost policy, decides whether ABA is covered and on what terms.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment** _(plan-dependent)_: Plan-dependent — precertification exists only if the member's plan includes it (shown on the ID card). MedCost's Comprehensive Outpatient Review list (January 2025) does not list 97151, 97152 or 0362T [1][2]
  - Ask the plan: Read the precertification contact and program on the back of the member's ID card; if MedCost is listed, call 800-722-2157 option 2.
- **Prior auth for treatment** _(plan-dependent)_: Plan-dependent — on plans with MedCost's Comprehensive Outpatient Review (indicated on the ID card), 97153, 97154, 97155, 97156, 97157, 97158 and 0373T are on the January 2025 list of services that should be pre-certified; plans without that program may carry no precert for ABA [1][2]
  - Ask the plan: Check the ID card for Comprehensive Outpatient Review; MedCost precert line 800-722-2157 option 2, fax 336-970-2098.

## At a glance

- **What it is:** Self-funded plan administrator (MedCost Benefit Services) plus a leased provider network (MedCost Network) in NC, SC and VA
- **Who sets the benefit:** The employer, in the plan document; the Summary Plan Description governs over MedCost medical policy
- **Precert:** Only if the plan includes it — shown on the ID card. Comprehensive Outpatient Review lists 97153–97158 and 0373T
- **Precert line:** 800-722-2157 option 2 · fax 336-970-2098 (when MedCost is the precert contact)
- **Claims:** EDI payer ID 56162 (NC/SC network) via Availity; 90-day filing limit, 180 days on NC fully insured plans
- **State mandate:** N.C.G.S. § 58-3-192 — may not reach a self-funded employer plan
- **Mandate age:** Where it applies, ABA may be limited to 18 and younger (parity-limited)
- **Mandate caps:** $40,000/yr cap, CPI-indexed from 2017 (parity-limited)
- **Exempt from mandate:** Non-grandfathered individual/small group; the State Health Plan; self-funded ERISA plans
- **Licensure:** NC Licensed Behavior Analyst (NCBALB)

## Find the payer, then the employer group

A MedCost logo does not always mean MedCost pays the claim. MedCost says payer partners "lease our provider network in North Carolina, South Carolina, and Virginia" and that "To identify the payer, you will need to consult the member ID card"; its published list of payer partners runs to several dozen third-party administrators and insurers. When MedCost Benefit Services is the payer, benefits, eligibility and claim status are in its provider portal; if you cannot tell who administers an employer's plan, MedCost's provider contact center (1-800-824-7406) will help identify it. [5][6][8][4][9]

When MedCost Benefit Services is the administrator, the plan is almost always self-funded: MedCost describes its clients as self-funded companies with 50 or more employees in NC, SC or VA, and sells a level-funded arrangement (a claims reserve with stop-loss) to smaller employers. MedCost's own medical policies "apply only to health benefit plans administered by MedCost Benefit Services", and "In the event of conflicting information between MedCost Medical Policy and a member's Summary Plan Description (SPD), the SPD will govern unless language within the SPD explicitly defers to Medical Policy." Capture the employer name and group number at intake and verify against that group: two families holding MedCost cards can have different ABA benefits. [5][6][8][4][9]

## Precertification: read the ID card

MedCost says "Some benefit plans include precertification requirements" and "If a member's benefit plan includes any precertification requirements, it will be indicated on the member's ID card." It runs two outpatient review programs, Advanced Imaging and Comprehensive Outpatient Review. The Comprehensive Outpatient Review list (January 2025) includes the ABA treatment codes 97153, 97154, 97155, 97156, 97157, 97158 and 0373T; the assessment codes 97151, 97152 and 0362T are not on it. Where MedCost is the precertification contact on the card, call 800-722-2157 and select option 2, or fax 336-970-2098. MedCost adds that "Precertification is not a guarantee of payment" — the plan document still decides coverage and limits. [1][2]

## Claims: payer ID 56162 through Availity

MedCost's provider manual (October 2025) says that however a member reaches the MedCost NC/SC Network — through a TPA that leases it or through MedCost Benefit Services itself — the ID card carries Medical EDI 56162 for electronic claims (54138 for the MedCost Virginia network), and that MedCost NC/SC takes electronic claims through Availity as its exclusive EDI gateway. A card administered by MedCost Benefit Services carries the MBS logo; a leased-network card carries the MedCost Network logo and the other administrator's details. Leased-payer claims without a group number are rejected. Network providers file within 90 days of the date of service, extended to 180 days for North Carolina fully insured plans under G.S. 58-3-225. Coordination of benefits is the claim administrator's job, and network providers must file claims for all MedCost plans regardless of the order of benefit determination. [3]

## The North Carolina mandate, and why it may not apply

N.C.G.S. § 58-3-192 requires health benefit plans to cover the screening, diagnosis and treatment of autism spectrum disorder, including "adaptive behavior treatment", which must be ordered by a licensed physician or licensed psychologist and provided or supervised by one of eight listed professionals (a board certified behavior analyst among them). Adaptive behavior treatment may be capped at $40,000 a year, indexed to CPI from 2017, and may be limited to people 18 or younger. Coverage cannot be denied because treatment is habilitative or educational, and cost sharing may be no less favourable than for substantially all medical services. The mandate does not apply to non-grandfathered individual and small-group plans that must cover essential health benefits, and "health benefit plan" (G.S. 58-3-167) excludes the State Health Plan and reaches other benefit arrangements only "to the extent permitted by" ERISA — so a self-funded private employer plan administered by MedCost generally answers to its own plan document and federal law instead. Government employers are a separate case (ERISA does not govern their plans), so ask rather than assume. [10][11]

## Licensure & rates in North Carolina

North Carolina licenses behavior analysts through the NC Behavior Analyst Licensure Board: a Licensed Behavior Analyst application needs a current BCBA or QBA certificate, a $250 application fee, a $14 criminal-history-check fee with a fingerprint card, and a Castle Branch background check (package VN90). MedCost publishes no ABA fee schedule publicly — rates for network providers sit behind its provider login — so treat reimbursement as part of network contracting. [12][13]

## Intake gates

The questions that decide whether a family can start with MedCost Benefit Services, and what they have to bring.

- **Age limit** _(plan-dependent)_: Set by the employer plan document. MedCost publishes no ABA age limit of its own in anything public. Where North Carolina's mandate reaches the plan, it allows adaptive behavior treatment to be limited to people 18 or younger — a quantitative limit that federal parity law constrains on group plans — but a self-funded private employer plan generally sits outside the mandate. [10][4]
  - Ask the plan: Benefits check against the employer group (MedCost provider portal, or 1-800-824-7406 to identify the administrator); ask for any ABA age limit in the plan document.
- **Referral required?** _(plan-dependent)_: Plan-dependent. MedCost publishes no referral rule for ABA. On a plan the North Carolina mandate reaches, adaptive behavior treatment must be ordered by a licensed physician or licensed psychologist; a self-funded plan sets its own rule in the plan document. [10][4]
  - Ask the plan: Ask at benefits verification whether the plan requires a physician or psychologist order for ABA; collect one regardless.
- **Prior-auth decision time** _(plan-dependent)_: MedCost publishes no ABA turnaround, so the clock depends on the plan type. A self-funded private employer plan follows the ERISA claims rule: a pre-service decision "not later than 15 days after receipt of the claim by the plan", extendable once by up to 15 days, and an urgent one "not later than 72 hours after receipt". A fully insured North Carolina policy follows G.S. 58-50-61(f): prospective and concurrent determinations within "three business days after the insurer obtains all necessary information", and in concurrent review the insurer "shall remain liable for health care services until the covered person has been notified of the noncertification." Government employer plans follow their own plan document. [14][15][1]
  - Ask the plan: Ask MedCost precert (800-722-2157 option 2) its expected turnaround for ABA and how early it wants the reauthorization request.
- **Other insurance (who pays first)** _(plan-dependent)_: Set by the employer plan document for a self-funded plan. MedCost's provider manual says "It is the responsibility of the claim administrator to handle all coordination of benefits" and that network providers "are required to file claims for all MedCost plans regardless of the order of benefit determination" — so file with MedCost even when it may be secondary. Federal program rules still sort government coverage: TRICARE is secondary to other health plans ("secondary payer to all health benefit, insurance and third-party payer plans") but primary to Medicaid; CHAMPVA "is the last payer to" other health insurance; and Medicaid pays after other liable third parties, so a MedCost plan pays before Medicaid for a child with both. [3][16][17][18]
  - Ask the plan: Collect both parents' plans, dates of birth and any custody order at intake; confirm primary/secondary with MedCost customer service before the first claim.

## Delivery and billing rules

Coverage decides whether MedCost Benefit Services 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.

- **Daily limits / MUEs** _(plan-dependent)_: Plan-dependent — any hour, visit or dollar limit on ABA is written into the employer's plan document; MedCost publishes none of its own. [4]
  - Ask the plan: Ask at benefits verification for any ABA hour, visit or dollar limit under this group.
- **Place of service** _(plan-dependent)_: Plan-dependent — MedCost publishes no ABA place-of-service rule, so covered settings follow the plan document. Where the North Carolina mandate reaches the plan, coverage may not be denied because treatment is habilitative or educational in nature. [10][4]
  - Ask the plan: Ask at benefits verification whether home, clinic, school and community sessions are covered under this group.
- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: MedCost's ABA medical policy or provider reference guide (behind the provider login). [4]

## What intake should collect for MedCost Benefit Services

- **ID card, front and back:** Shows who the payer is (MedCost or a network-leasing partner) and whether the plan has a precertification program and who to call.
- **Employer name and group number:** The benefit lives in the employer plan document; MedCost's medical policy yields to the Summary Plan Description.
- **Self-funded, level-funded, or insured; private or government employer:** Decides whether the North Carolina mandate can reach the plan.
- **Diagnosis report and order:** ASD diagnosis with the diagnosing clinician's credentials; where the mandate applies, ABA must be ordered by a licensed physician or psychologist.
- **Network status:** Confirm the practice is in the MedCost Network (or the plan's national partner network) for this plan.
- **Group number for the claim:** MedCost rejects leased-payer claims without a group number (loop 2000B SBR03).

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

## Verification of benefits (VOB) data

How MedCost Benefit Services ABA benefits route and read on an eligibility check. Data last updated 2026-09-27.

### EDI routing

- **Payer ID (pVerify):** 00439 — pVerify GetAllPayers directory (credentialed API; LeadTrap PayerDirectoryService). LeadTrap harvested 00439 "MedCost Benefit Services" on 2026-08-17; pverify.com/payer-list is Cloudflare-walled to this refresh.
- **Payer ID (Availity):** 56162 — Claims payer ID per the October 2025 Provider Manual — confirm Availity also routes 270/271 eligibility on 56162.
- **Behavioral health administrator:** plan-dependent — Not a research gap: whether behavioral health is carved out, and to whom, is the employer plan sponsor's decision. Ask per group.

### How the 271 reports ABA benefits

- **Deductible applies to ABA:** plan-dependent — Self-funded plan designs vary by employer; read the cost share off the 271 or the Summary Plan Description per member.
- **Cost-share type:** plan-dependent
- **Copay unit:** plan-dependent

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | plan-dependent | plan-dependent — not on MedCost's January 2025 Comprehensive Outpatient Review list; precert only if the employer plan document requires it | plan-dependent per plan-dependent | plan-dependent | plan-dependent | — |
| 97152 | plan-dependent | plan-dependent — not on MedCost's January 2025 Comprehensive Outpatient Review list; precert only if the employer plan document requires it | plan-dependent per plan-dependent | plan-dependent | plan-dependent | — |
| 97153 | plan-dependent | plan-dependent — on plans with MedCost Comprehensive Outpatient Review (shown on the ID card) this code is on the January 2025 precertification list; call 800-722-2157 option 2 or fax 336-970-2098 when MedCost is the precert contact | plan-dependent per plan-dependent | plan-dependent | plan-dependent | — |
| 97154 | plan-dependent | plan-dependent — on plans with MedCost Comprehensive Outpatient Review (shown on the ID card) this code is on the January 2025 precertification list; call 800-722-2157 option 2 or fax 336-970-2098 when MedCost is the precert contact | plan-dependent per plan-dependent | plan-dependent | plan-dependent | — |
| 97155 | plan-dependent | plan-dependent — on plans with MedCost Comprehensive Outpatient Review (shown on the ID card) this code is on the January 2025 precertification list; call 800-722-2157 option 2 or fax 336-970-2098 when MedCost is the precert contact | plan-dependent per plan-dependent | plan-dependent | plan-dependent | — |
| 97156 | plan-dependent | plan-dependent — on plans with MedCost Comprehensive Outpatient Review (shown on the ID card) this code is on the January 2025 precertification list; call 800-722-2157 option 2 or fax 336-970-2098 when MedCost is the precert contact | plan-dependent per plan-dependent | plan-dependent | plan-dependent | — |
| 97157 | plan-dependent | plan-dependent — on plans with MedCost Comprehensive Outpatient Review (shown on the ID card) this code is on the January 2025 precertification list; call 800-722-2157 option 2 or fax 336-970-2098 when MedCost is the precert contact | plan-dependent per plan-dependent | plan-dependent | plan-dependent | — |
| 97158 | plan-dependent | plan-dependent — on plans with MedCost Comprehensive Outpatient Review (shown on the ID card) this code is on the January 2025 precertification list; call 800-722-2157 option 2 or fax 336-970-2098 when MedCost is the precert contact | plan-dependent per plan-dependent | plan-dependent | plan-dependent | — |
| 0362T | plan-dependent | plan-dependent — not on MedCost's January 2025 Comprehensive Outpatient Review list; precert only if the employer plan document requires it | plan-dependent per plan-dependent | plan-dependent | plan-dependent | — |
| 0373T | plan-dependent | plan-dependent — on plans with MedCost Comprehensive Outpatient Review (shown on the ID card) this code is on the January 2025 precertification list; call 800-722-2157 option 2 or fax 336-970-2098 when MedCost is the precert contact | plan-dependent per plan-dependent | plan-dependent | plan-dependent | — |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** Verify per employer group, not per carrier: MedCost medical policy yields to the member's Summary Plan Description. N.C.G.S. 58-3-192 generally does not reach a self-funded private employer plan. A MedCost Network logo may sit on another administrator's card — the ID card names the payer.

### Contacts

- **Provider services phone:** 1-800-824-7406
- **Portal:** [MedCost Benefit Services provider portal (healthx)](https://secure.healthx.com/mbsprovider.aspx)
- **Fax:** 336-970-2098 (precertification, when MedCost is the precert contact on the ID card)

Questions to ask on a verification call:

- Who is the claim administrator on this card — MedCost Benefit Services or a partner leasing the MedCost Network?
- Which employer group sponsors this plan, and is it self-funded, level-funded or fully insured?
- Does this group carry Comprehensive Outpatient Review, and do 97153-97158 need precertification?
- What ABA hour, visit, age or dollar limits does the plan document apply, and is telehealth covered?

### VOB data sources

- https://www.medcost.com/sites/default/files/2025-10/MedCost%20Provider%20Manual%20Version%20October%202025.pdf (accessed 2026-09-27)
- https://www.medcost.com/providers/coverage-and-claims/payer-partners (accessed 2026-09-27)
- https://www.medcost.com/medical-policies (accessed 2026-09-27)
- https://www.medcost.com/providers/coverage-and-claims/precertification (accessed 2026-09-27)
- https://www.medcost.com/sites/default/files/2025-01/Comprehensive%20Outpatient%20Services%20Requiring%20Precertification%20-%20January%202025.pdf (accessed 2026-09-27)

## Common questions

### Does MedCost cover ABA therapy?

It depends on the employer plan. MedCost Benefit Services administers mostly self-funded employer plans, and its medical policies yield to the plan's Summary Plan Description, so the employer decides whether ABA is covered and on what terms. Verify against the employer group, not the carrier.

### Does MedCost require prior authorization for ABA?

Only if the member's plan includes a precertification program, which is shown on the ID card. Under MedCost's Comprehensive Outpatient Review (January 2025 list), 97153–97158 and 0373T should be pre-certified; the assessment codes 97151, 97152 and 0362T are not on the list. Call 800-722-2157 option 2 when MedCost is the precert contact.

### Does the North Carolina autism mandate apply to a MedCost plan?

Often not. N.C.G.S. § 58-3-192 applies to "health benefit plans", a term that reaches other benefit arrangements only to the extent ERISA allows, so a self-funded private employer plan generally follows its own plan document. Establish funding type and employer type first.

### The card says MedCost, but MedCost is not the payer. Why?

MedCost leases its provider network to dozens of other administrators and insurers. The ID card shows who the payer is; if it is unclear, MedCost's provider contact center (1-800-824-7406) can help identify the claim administrator.

## Primary sources

1. [MedCost — Precertification (provider page)](https://www.medcost.com/providers/coverage-and-claims/precertification)
2. [MedCost — Comprehensive Outpatient Review Services Requiring Precertification (January 2025)](https://www.medcost.com/sites/default/files/2025-01/Comprehensive%20Outpatient%20Services%20Requiring%20Precertification%20-%20January%202025.pdf)
3. [MedCost — Provider Manual (MedCost Network, October 2025)](https://www.medcost.com/sites/default/files/2025-10/MedCost%20Provider%20Manual%20Version%20October%202025.pdf)
4. [MedCost — Medical Policies](https://www.medcost.com/medical-policies)
5. [MedCost — Payer Partners](https://www.medcost.com/providers/coverage-and-claims/payer-partners)
6. [MedCost — Who We Serve](https://www.medcost.com/employers/why-medcost/who-we-serve)
7. [MedCost — Network](https://www.medcost.com/employers/why-medcost/network)
8. [MedCost — Level Funding](https://www.medcost.com/employers/benefits-plans/level-funding)
9. [MedCost — Contact Us](https://www.medcost.com/contact-us)
10. [N.C.G.S. § 58-3-192 — coverage for autism spectrum disorder](https://www.ncleg.gov/EnactedLegislation/Statutes/HTML/BySection/Chapter_58/GS_58-3-192.html)
11. [N.C.G.S. § 58-3-167 — "health benefit plan" defined](https://www.ncleg.gov/EnactedLegislation/Statutes/HTML/BySection/Chapter_58/GS_58-3-167.html)
12. [NCBALB — Requirements for Licensure](https://ncbehavioranalystboard.org/requirements-for-licensure/)
13. [MedCost — Providers](https://www.medcost.com/providers)
14. [29 CFR 2560.503-1(f) — ERISA claims procedure: group health plan decision timeframes](https://www.ecfr.gov/current/title-29/section-2560.503-1)
15. [N.C.G.S. § 58-50-61 — utilization review (prospective/concurrent determinations)](https://www.ncleg.gov/EnactedLegislation/Statutes/HTML/BySection/Chapter_58/GS_58-50-61.html)
16. [32 CFR 199.8 — TRICARE double coverage](https://www.ecfr.gov/current/title-32/subtitle-A/chapter-VII/subchapter-M/part-199/section-199.8)
17. [38 CFR 17.276 — CHAMPVA is the last payer to other health insurance](https://www.ecfr.gov/current/title-38/section-17.276)
18. [42 CFR 433.139 — payment of claims involving third-party liability](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)

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.