Trillium Health Resources, an eastern-NC Tailored Plan, publishes the single best reference document of the Tailored Plans: a Medicaid Child Behavioral Health Benefit Plan (revised August 31, 2026) carrying a complete RB-BHT service definition that cites CCP 8F and the 2021 State Plan Amendment as its sources. Nothing in it is clinically distinct from the state baseline — which is exactly what makes it a reliable operational reference for TAR submissions.
Every RB-BHT code (97151–97157) requires a TAR — prior authorization — including telephonic and telehealth delivery. The initial request needs the written assessment, diagnosis documentation from a validated tool, and the MD/DO/LP service order; treatment requests add a complete treatment plan signed by the LQASP and the legally responsible person, plus a discharge plan. Under the finalized CCP 8F (effective 8/1/2026), plans at or under 16 hours/week keep 180-day initial and reauthorization periods, while plans above 16 hours/week move to 90-day initial and reauthorization periods; reauth is due before the current one expires either way, and all services are subject to post-payment review. Existing prior authorizations aren't affected by the change — no action is needed, and no existing PA's duration will be reduced; the new 90-day cadence binds only future reauthorizations. Units run in 15-minute increments with no published unit caps.[4][4][5][6][2]
Telehealth mechanics, now finalized under CCP 8F effective August 1, 2026: telehealth is removed entirely — no documented-necessity exception — for the paraprofessional-delivered codes 97152, 97153, and 97154. 97151 retains telehealth eligibility with clinical justification, and 97155 retains it but capped at a maximum of 50% of total 97155 billing per beneficiary per 180-calendar-day period. 97156/97157 keep their own separate telephonic/KX caregiver-access-barrier exception, unchanged.[4][4][5][6][2]
Treatment plans follow the rewritten 8F review rule rather than a fixed calendar: each goal is reviewed at its own target date (short-range goals never more than 12 months out), and the plan is reviewed again whenever the member's needs, the provider or the services change — plus the review, modification and resubmission Trillium requires with every reauthorization. On school: Trillium's benefit plan lists school-based settings among the places RB-BHT may be delivered, individually justified in the treatment plan with the family, and publishes no Trillium-specific school restriction beyond the state rule — which excludes services that teach academic subjects or substitute for a teacher, teacher's aide or tutor, and services available under IDEA or other educational programs that duplicate or supplant the authorized plan, and leaves hours spent in educational settings and receiving IEP services out of the treatment-hour count.[4][4][5][6][2]
Reauthorization packet: Trillium’s benefit plan (rev. 8/31/2026) lists three things. First, reauth “must be submitted before the initial or concurrent auth expiring.” Second, the treatment plan “must be reviewed, modified, & submitted for reauth.” Third, the provider submits “applicable records that support the member has met the medical necessity criteria.” The benefit plan names no graph requirement and no separate data-recency rule, so CCP 8F’s goal-level baselines, measurement methods and progress milestones are the standard.[4][4][5][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.[4][4][5][6][2]
Closed. Trillium's Provider Communication 005 (July 9, 2026) says North Carolina's 2026 budget act "requires each Prepaid Health Plan (PHP) to establish a mandatory closed network" for peer support and research-based behavioral health treatment, "with the authority to determine which providers participate," and that "Trillium will be maintaining a closed network for both services." That notice replaces the open-network wording in Trillium's provider manual (effective July 20, 2026) for RB-BHT.[7][8]
Trillium did not say how it will handle new applicants. Ask Trillium provider network contracting before planning on a new Trillium RB-BHT contract.[7][8]
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.[9][10][6][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.[9][10][6][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 Trillium’s network has to be enrolled with NC Medicaid as well.[9][10][6][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.[5][18][4]
Trillium’s Tailored Plan manual describes utilization management as “conducting initial, concurrent and retrospective reviews of services,” and its Medicaid Child BH benefit plan (rev. 8/31/2026) is explicit about EPSDT requests: “There is no retroactive prior authorization for services that require prior authorization. Services delivered without prior authorization will be denied.” The only exception left is the state’s: retroactive Medicaid eligibility.[5][18][4]
Yes. Trillium’s 2026 Claims Billing Guide tells contracted providers to “reference their contract with Trillium for the days to file a claim timely.” Non-contracted providers have 365 days to submit a Medicaid-funded claim, and state-funded claims are due within 90 calendar days. The guide restates the Tailored Plan rule: Trillium may require claims within 365 calendar days of the date of service but may not set a limit shorter than 180 days. A late claim still counts 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. NC Medicaid’s prompt-payment fact sheet puts the Tailored Plan window at 365 days since July 1, 2024, corrected claims included. To ask for a time-limit override, use Trillium’s Claims Request Form (CRF).[12][16][2][1]
Payment clock: Trillium has 18 calendar days to say whether a claim is clean or pend it. It must pay or deny a clean claim within the lesser of 30 calendar days or the first scheduled reimbursement cycle after adjudication. It pays 18% annual interest on late Medicaid-funded clean claims; state-funded claims earn none.[12][16][2][1]
Payment cycle: “The Checkwrite Schedule for Medicaid Direct and Tailored Plan services is posted on the Trillium’s website and will occur weekly with the exception of a few holidays.” Remittance advices and 835 files are available “the day after the checkwrite.” Partial refunds and other changes to a paid claim are made only with a replacement claim (frequency 7); a full refund is a voided claim (frequency 8) or a check. The guide publishes no weekly submission cutoff, so take it from the posted checkwrite schedule.[12][16][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][16][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][16][2][1]
From October 1, 2026 Trillium moved Tailored Plan claims, behavioral health included, to a unified claims system. Providers enter claims and authorizations in the iTransact portal (provider.trilliumitransact.com), upload 837s by SFTP, or bill through Optum/Change Healthcare, The SSI Group or Availity under the new Tailored Plan payer ID 43072. NC Medicaid Direct and state-funded claims stay in Trillium’s Business System through Provider Direct, under payer IDs 56089 (Change Healthcare) and 43071 (SSI and Availity). A Tailored Plan claim sent to the Medicaid Direct system is denied. Tailored Plan claims for dates of service back to July 1, 2024 that are still within timely filing go to the new system.[13][14][15]
Access starts with the agency’s system administrator, who completes the iTransact System Administrator training in My Learning Campus and the Provider Profile Readiness Form. Third-party billers cannot be system administrators, and logins are issued per EIN. Trillium’s FAQ answers the setup question directly: asked where to get the “Vendor ID and access code” the new login asks for, Trillium says “Vendor ID’s and any additional codes needed are emailed to the requestor during the onboarding process.” Trillium publishes no format for either. If the email has not arrived, use the Contact Us button on the provider onboarding portal.[13][14][15]
Yes, taxonomy is required. Trillium’s billing guide says “Taxonomy codes are required on claim forms,” and the taxonomy for the billing, rendering and attending providers must be one the provider is enrolled for with NCTracks. On the CMS-1500, “the individual rendering the service is reported in 24J”: NPI in the unshaded area, rendering taxonomy in the shaded area with qualifier ZZ in 24I. The billing provider’s taxonomy goes in 33b. A missing or invalid taxonomy denies the claim. Trillium checks the claim’s taxonomy against the provider enrollment file and prices the claim on it.[12]
Start with a reconsideration request to the Claims Relations Team at ClaimsSupport@trilliumnc.org. Include the provider name and number, the member, the claim numbers and the reason. To appeal a claim action such as a denial or underpayment, send a written appeal naming the claim numbers and the action appealed. Send it through the provider portal for Medicaid Direct, by fax to (252) 215-6879, by secure email to Appeals@TrilliumNC.org, or by mail to Trillium Health Resources, Attn: Appeals Department, PO Box 12797, Durham, NC 27709. Trillium says the appeal filing timeframes are printed on the remittance advice.[12]
The questions that decide whether a family can start with Trillium Health Resources (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 — no upper age bound. Trillium is explicit about it: its Medicaid Child Behavioral Health Benefit Plan lists RB-BHT for "Children, Adolescents and Adults," reflecting the 2021 State Plan Amendment that extended coverage past 21. Under-21 members carry EPSDT; under-3s may start on a provisional diagnosis.[5][4][4]
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.[5][4]
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.[5][4]
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).[5][4]
Follows the NC Medicaid rule, enforced at the TAR: the initial request needs the written assessment, diagnosis documentation from a validated tool, and the MD/DO/Licensed Psychologist service order; treatment requests add a complete treatment plan signed by the LQASP and the legally responsible person, plus a discharge plan. Every RB-BHT code (97151–97157) requires a TAR, telehealth and telephonic delivery included.[5][4][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.[5][4][2]
Trillium’s July 2026 manual lists "7 calendar days for a routine request" and "72 hours for an expedited request" alongside timely responses to Treatment Authorization Requests (TARs), and says formal decisions are made only "when a complete request is received." Submit TARs "at least 7 days prior to the end date of the current authorization"; for RB-BHT the benefit plan adds "Reauth must be submitted prior to initial or concurrent auth expiring" (up to 180 days at 16 hours a week or fewer, up to 90 above). A service cannot be authorized "if requested more than 30 days in advance." The 7-day figure matches the federal managed-care ceiling for NC plans from July 1, 2026.[18][4][19]
Trillium pays last, and it answers the secondary-auth question the opposite way to most plans: "The requested service cannot be authorized if the member has private insurance, and the provider should seek authorization from primary insurance source. Medicaid is the payor of last resort." So for a child with commercial coverage, get the ABA authorization from the commercial plan, "Bill all first - and third-party payers prior to submitting claims to Trillium", and record the other payer’s payment or denial on the claim (keep the EOB). Claims go to the primary insurer first, "then secondary insurance after the initial EOB has been received." Exceptions paid without TPL first include medical support enforcement (coverage through an absent parent) and "Preventive Pediatric Services including … EPSDT". Under federal rules TRICARE pays before Medicaid and CHAMPVA pays first when the child is also Medicaid-eligible.[4][18][12][20][21]
Coverage decides whether Trillium Health Resources (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.[5][4]
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.[5][4]
Two different ceilings. Per day, a claim edit: Trillium’s Claims Billing Guide 2026 says MUEs "define for each HCPCS or CPT code, the maximum units of service that a provider should bill under most circumstances for a member on a single date of service" and "Any claims billed in violation of the NCCI methodologies will be denied"; NC Medicaid’s billing guidance tells every health plan to apply NCCI and MUE edits (§3.6.2). 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 benefit plan sets no unit cap of its own ("Units: One unit = 15 minutes"), so CCP 8F governs: 180-day initial and reauthorization cycles at or under 16 hours a week, 90-day cycles above it, with reauthorization due before the current one expires and all services subject to post-payment review. Existing prior authorizations are unaffected by the change and none will be shortened.[5][4][12][2][3][6]
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.[5][4]
Follows the NC Medicaid rule, restated in Trillium's benefit plan (rev. 8/31/2026): place-of-service decisions are documented in the treatment plan and made individually with the family, and settings may include clinic-, home-, school- or community-based settings in any combination, advancing from a structured setting toward the member's natural setting. Trillium publishes no school restriction of its own; the state exclusions apply — no services teaching academic subjects or substituting for a teacher, teacher's aide or tutor, and nothing available through IDEA or other educational programs that duplicates or supplants the authorized plan. Telehealth or telephonic claims carry the provider’s usual place-of-service code.[5][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. Trillium’s 2026 billing guide adds the claim mechanics: “the individual rendering the service is reported in 24J” with NPI and rendering taxonomy (qualifier ZZ), the billing provider’s taxonomy goes in 33b, and a missing or invalid taxonomy denies the claim.[5][12][4]
Yes — RB-BHT under CCP 8F, with a TAR (prior authorization) required for every code including telehealth delivery, in 180-day cycles (90-day for plans above 16 hours/week under the finalized 8F, effective 8/1/2026).
Its benefit plan lists RB-BHT for "Children, Adolescents and Adults," reflecting the 2021 State Plan Amendment that extended NC RB-BHT coverage past age 21.
Not beyond the state rule. Trillium's benefit plan (rev. 8/31/2026) lists school-based settings among the places RB-BHT may be delivered, justified in the treatment plan with the family. CCP 8F excludes services that teach academic subjects or stand in for a teacher, aide or tutor, and services available through IDEA or other educational programs that duplicate or supplant the authorized plan; hours spent in educational settings and receiving IEP services are not counted in the treatment hours.
No, not for RB-BHT. Trillium's Provider Communication 005 (July 9, 2026) says "Trillium will be maintaining a closed network" for RB-BHT and peer support, as S.L. 2026-41 §9E.22 requires of every NC Medicaid health plan. That overrides the open-network wording in its July 20, 2026 provider manual for these services. Ask Trillium provider network contracting before planning on a new RB-BHT contract.
Only in part, under the finalized CCP 8F (effective 8/1/2026): telehealth is removed entirely for 97152, 97153, and 97154; 97151 keeps it with clinical justification; 97155 keeps it capped at 50% of billing per beneficiary per 180 days; 97156/97157 keep their separate telephonic/KX caregiver-barrier exception.
Trillium 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 Trillium 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)).
No, except for retroactive Medicaid eligibility. Trillium’s benefit plan says “There is no retroactive prior authorization for services that require prior authorization,” and services delivered without one are denied.
Yes. Contracted providers file within the window in their Trillium contract. Non-contracted providers have 365 days for Medicaid-funded claims, and state-funded claims are due in 90 days. NC Medicaid sets the Tailored Plan window at 365 days, and Trillium may not set fewer than 180. Use the Claims Request Form for a time-limit override.
Trillium emails them. Its Unified Claims System FAQ (rev. 9/30/2026) says “Vendor ID’s and any additional codes needed are emailed to the requestor during the onboarding process.” Your system administrator must first complete the iTransact training in My Learning Campus and the Provider Profile Readiness Form. Logins are per EIN, and third-party billers cannot be system administrators.
From October 1, 2026: 43072 at Optum/Change Healthcare, The SSI Group and Availity, or direct entry in iTransact. NC Medicaid Direct and state-funded claims keep 56089 (Change Healthcare) or 43071 (SSI, Availity) through Provider Direct.
Yes. Billing, rendering and attending taxonomy codes are required and must match the provider’s NCTracks enrollment: rendering in box 24J (shaded, qualifier ZZ) and billing in 33b. A missing or invalid taxonomy denies the claim.
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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