---
title: Trillium Health Resources ABA coverage (NC Tailored Plan).
url: "https://carelu.com/payers/trillium-health-resources"
markdown_url: "https://carelu.com/payers/trillium-health-resources.md"
state: NC (North Carolina)
payer: Trillium Health Resources (NC Tailored Plan)
kind: Medicaid managed care plan (MCO)
parent_program: North Carolina Medicaid
description: "How Trillium Health Resources administers NC Medicaid RB-BHT (ABA) — its benefit-plan service definition citing CCP 8F, 180-day TAR cycles, adult coverage under the 2021 SPA, and telehealth modifier rules."
last_reviewed: October 2026
vob_data_updated: 2026-10-15
---

# Trillium Health Resources ABA coverage (NC Tailored Plan).

_Payer Guide · Trillium (NC) · Last updated October 2026 · 17 primary sources_

> Tailored Plan with the best single reference doc: tiered 180/90-day TARs, adult coverage, GT/KX modifier rules.

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.

This plan administers the **North Carolina Medicaid** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [North Carolina Medicaid guide](https://carelu.com/payers/north-carolina-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — TAR (prior authorization) on all RB-BHT codes, telehealth included [4][5]
- **Prior auth for treatment**: Required — TAR on every RB-BHT code, TIERED by intensity: Trillium's benefit plan (rev. 8/31/2026) allows initial and reauth requests of up to 180 days for treatment plans of 16 service hours a week or less, or up to 90 days above 16; reauth must be submitted before the initial or concurrent auth expires, with the treatment plan reviewed, modified and resubmitted [4][5]
- **Autism diagnosis required?**: Yes — ASD via a validated diagnostic tool; under-3s may start on a provisional diagnosis [5]

## At a glance

- **Plan type:** NC Tailored Plan (public LME/MCO, eastern NC)
- **Clinical rules:** CCP 8F via its benefit-plan service definition
- **Prior auth:** TAR required on all codes 97151–97157, telehealth included
- **Auth periods:** Tiered by intensity per CCP 8F §5.1/5.1.1 — up to 180 calendar days at ≤16 hrs/week, up to 90 above; renew before expiry
- **Ages:** "Children, Adolescents and Adults" — reflects the 21+ SPA coverage
- **Rates:** ≥100% of the NC Medicaid fee schedule (state floor)

## How Trillium runs RB-BHT authorization

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]

## Is Trillium's ABA network open or closed?

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]

## Can an out-of-state BCBA treat a North Carolina member, including by telehealth?

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]

## Can Trillium authorize ABA retroactively?

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]

## Does Trillium have a timely filing window?

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]

## Setting up Trillium’s iTransact portal: Vendor ID, access code and the new payer ID

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]

## Does Trillium require taxonomy codes on the claim, and whose NPI goes in box 24J?

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]

## How do I dispute a Trillium claim decision?

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]

## Intake gates

The questions that decide whether a family can start with Trillium Health Resources (NC Tailored Plan), and what they have to bring.

- **Age limit**: 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]
- **Diagnosis recency**: 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]
- **Who may diagnose**: Follows the NC Medicaid rule: a non-provisional ASD diagnosis comes from a Licensed Psychologist, a supervised Licensed Psychological Associate, or a physician (MD or DO); a Licensed School Psychologist evaluation may be used where the required testing is included; a provisional under-3 diagnosis may also come from a trained master’s-level licensed clinician within scope. [5][4]
- **Diagnostic tools required**: Follows the NC Medicaid rule: the ASD diagnosis must use BOSA, Tele-ASD-Peds, ADOS-2, or CARS2-ST/CARS2-HF; screeners, educational determinations and informal impressions cannot start services. The packet also needs a skills assessment (VB-MAPP, ABLLS-R or ESDM Curriculum Checklist), an FBA where challenging behaviors are targeted, and an adaptive behavior assessment within 3 years (VABS-3, ABAS-3 or DP-4). [5][4]
- **Referral required?**: 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]
- **Telehealth**: 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]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: 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]

## Delivery and billing rules

Coverage decides whether Trillium Health Resources (NC Tailored Plan) pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: Follows the NC Medicaid rule: at least 10% of paraprofessional-delivered services must involve LQASP observation and direction, and above 200 paraprofessional hours per 180 days the LQASP-to-paraprofessional ratio must sit between 10% and 20%, documented in the treatment plan with deviations clinically justified. Incidental supervision is not billable. 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]
- **Concurrent billing (97153 + 97155)**: Follows the NC Medicaid rule: 97153 or 97154 may be billed concurrently with 97155 when a paraprofessional delivers the direct service under an eligible provider’s observation, but a single rendering provider may not bill 97153/97154 and 97155 simultaneously. 97151, 97152, 97156 and 97157 allow no concurrent billing, and non-RB-BHT services may not be billed for the same clock time. 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]
- **Daily limits / MUEs**: 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]
- **Session-note signature**: Follows the NC Medicaid rule: the staff member who delivered the service signs the note with credentials (professional) or job title (paraprofessional), and an LQASP or C-QP is not required to countersign a note written by non-LQASP/C-QP staff. A full note is required per contact per date of service with the elements listed in 8F subsection 5.5.1, and the treatment plan is signed and dated by the LQASP and the consenting party before services begin. [5][4]
- **Place of service**: 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]
- **Bill as provider**: Follows the NC Medicaid rule: a professional CMS-1500/837P claim through the plan, with Attachment B fixing which provider type may render each code; behavior technicians must hold RBT or ABAT certification within 120 calendar days of hire or of the agency’s first Medicaid enrollment, and all LQASPs and C-QPs must enroll as in-state NC providers as of August 2, 2026. 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]

## What intake should collect for Trillium Health Resources (NC Tailored Plan)

- **Assessment + service order:** Written assessment, validated-tool diagnosis documentation, and the MD/DO/LP order — all required at the initial TAR.
- **Signatures:** Treatment plans need the LQASP and the legally responsible person's signatures.
- **Reauth calendar:** 180-day cycles for plans ≤16 hrs/week, 90-day cycles for plans >16 hrs/week (per the finalized CCP 8F, eff. 8/1/2026), with renewal due before expiry — put it on the calendar at intake.
- **Age:** Trillium's benefit plan covers adults too — don't screen out 21+ inquiries reflexively.

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

## Verification of benefits (VOB) data

How Trillium Health Resources (NC Tailored Plan) ABA benefits route and read on an eligibility check. Data last updated 2026-10-15.

### EDI routing

- **Payer ID (Availity):** 43072 — Corrected 2026-10-07: Tailored Plan claims moved to Trillium's unified claims system on 10/1/2026 under payer ID 43072 at Change Healthcare, The SSI Group and Availity (Trillium FAQ rev. 9/30/2026; Claims Submission Guidelines eff. 10/1/2026). The old 56089 (Change Healthcare) / 43071 (SSI, Availity) IDs now apply only to NC Medicaid Direct and State-funded claims — a Tailored Plan claim sent there denies.
- **Payer ID (Change Healthcare / Optum):** 43072 — Was 56089 until 9/30/2026; 43072 for Tailored Plan dates of service processed from 10/1/2026. Use 56089 only for a member on NC Medicaid Direct.
- **Supports 270/271 eligibility:** Yes — Trillium FAQ Q47 (rev. 9/30/2026): providers can upload a 270 EDI file and receive a 271 in return; eligibility for Tailored Plan members also shows in iTransact. Real-time vs batch not stated.
- **Behavioral health administrator:** none — Trillium is itself the LME/MCO administering behavioral health (including RB-BHT) directly — inferred from its role as a Tailored Plan and from its own claims protocol routing BH claims in-house (not to a third-party administrator).
- **ABA rides on:** behavioral health benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required — TAR (initial + reauth up to 180 days at 16 service hrs/week or less, up to 90 days above 16, per Trillium's benefit plan rev. 8/31/2026; telehealth and telephonic included); reauth due before current auth expires | 32 units per date of service — CMS Medicaid NCCI practitioner MUE (DOS 10/1–12/31/2026), a claim edit NC Medicaid and its health plans apply; units above it on one date of service deny regardless of the authorization per Per authorization period (CCP 8F §5.1/5.1.1, eff. 8/1/2026): up to 180 days at 16 hrs/week or fewer, up to 90 days above 16 hrs/week — initial and reauth alike | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | Yes — GT modifier, with clinical justification in the beneficiary’s Treatment Plan (CCP 8F Attachment A, eff. 8/1/2026). Not telephonic. | GT (telehealth) |
| 97152 | Yes | Required — TAR (initial + reauth up to 180 days at 16 service hrs/week or less, up to 90 days above 16, per Trillium's benefit plan rev. 8/31/2026; telehealth and telephonic included); reauth due before current auth expires | 16 units per date of service — CMS Medicaid NCCI practitioner MUE (DOS 10/1–12/31/2026), a claim edit NC Medicaid and its health plans apply; units above it on one date of service deny regardless of the authorization per Per authorization period (CCP 8F §5.1/5.1.1, eff. 8/1/2026): up to 180 days at 16 hrs/week or fewer, up to 90 days above 16 hrs/week — initial and reauth alike | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | No — telehealth was removed for 97152, 97153 and 97154 by the CCP 8F rewrite effective 8/1/2026 (Attachment A: not telehealth billable, not telephonic billable). | — |
| 97153 | Yes | Required — TAR (initial + reauth up to 180 days at 16 service hrs/week or less, up to 90 days above 16, per Trillium's benefit plan rev. 8/31/2026; telehealth and telephonic included); reauth due before current auth expires | 32 units per date of service — CMS Medicaid NCCI practitioner MUE (DOS 10/1–12/31/2026), a claim edit NC Medicaid and its health plans apply; units above it on one date of service deny regardless of the authorization per Per authorization period (CCP 8F §5.1/5.1.1, eff. 8/1/2026): up to 180 days at 16 hrs/week or fewer, up to 90 days above 16 hrs/week — initial and reauth alike | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | No — telehealth was removed for 97152, 97153 and 97154 by the CCP 8F rewrite effective 8/1/2026 (Attachment A: not telehealth billable, not telephonic billable). | — |
| 97154 | Yes | Required — TAR (initial + reauth up to 180 days at 16 service hrs/week or less, up to 90 days above 16, per Trillium's benefit plan rev. 8/31/2026; telehealth and telephonic included); reauth due before current auth expires | 18 units per date of service — CMS Medicaid NCCI practitioner MUE (DOS 10/1–12/31/2026), a claim edit NC Medicaid and its health plans apply; units above it on one date of service deny regardless of the authorization per Per authorization period (CCP 8F §5.1/5.1.1, eff. 8/1/2026): up to 180 days at 16 hrs/week or fewer, up to 90 days above 16 hrs/week — initial and reauth alike | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | No — telehealth was removed for 97152, 97153 and 97154 by the CCP 8F rewrite effective 8/1/2026 (Attachment A: not telehealth billable, not telephonic billable). | — |
| 97155 | Yes | Required — TAR (initial + reauth up to 180 days at 16 service hrs/week or less, up to 90 days above 16, per Trillium's benefit plan rev. 8/31/2026; telehealth and telephonic included); reauth due before current auth expires | 24 units per date of service — CMS Medicaid NCCI practitioner MUE (DOS 10/1–12/31/2026), a claim edit NC Medicaid and its health plans apply; units above it on one date of service deny regardless of the authorization per Per authorization period (CCP 8F §5.1/5.1.1, eff. 8/1/2026): up to 180 days at 16 hrs/week or fewer, up to 90 days above 16 hrs/week — initial and reauth alike | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | Yes, capped — GT modifier; telehealth may be used up to a maximum of 50% of total 97155 billing per beneficiary per 180-calendar-day period, with clinical justification in the Treatment Plan for more (CCP 8F Attachment A, eff. 8/1/2026). The observing provider may observe via telehealth while the technician delivers in person. | GT (telehealth) |
| 97156 | Yes | Required — TAR (initial + reauth up to 180 days at 16 service hrs/week or less, up to 90 days above 16, per Trillium's benefit plan rev. 8/31/2026; telehealth and telephonic included); reauth due before current auth expires | 16 units per date of service — CMS Medicaid NCCI practitioner MUE (DOS 10/1–12/31/2026), a claim edit NC Medicaid and its health plans apply; units above it on one date of service deny regardless of the authorization per Per authorization period (CCP 8F §5.1/5.1.1, eff. 8/1/2026): up to 180 days at 16 hrs/week or fewer, up to 90 days above 16 hrs/week — initial and reauth alike | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | Yes — GT modifier for telehealth (audio-visual). Telephonic (audio-only, KX modifier) also allowed, but ONLY when the caregiver's physical/behavioral health status or an access barrier (transportation, technology) prevents in-person or telehealth participation (CCP 8F §3.1.2 and Attachment A, eff. 8/1/2026). | GT (telehealth), KX (telephonic, caregiver-barrier criteria only) |
| 97157 | Yes | Required — TAR (initial + reauth up to 180 days at 16 service hrs/week or less, up to 90 days above 16, per Trillium's benefit plan rev. 8/31/2026; telehealth and telephonic included); reauth due before current auth expires | 16 units per date of service — CMS Medicaid NCCI practitioner MUE (DOS 10/1–12/31/2026), a claim edit NC Medicaid and its health plans apply; units above it on one date of service deny regardless of the authorization per Per authorization period (CCP 8F §5.1/5.1.1, eff. 8/1/2026): up to 180 days at 16 hrs/week or fewer, up to 90 days above 16 hrs/week — initial and reauth alike | home (primary private residence), office/clinic, school or work, community / place of recreation or socialization, (CCP 8F Section F is narrative only — no POS numeric codes given) | Yes — GT modifier for telehealth (audio-visual). Telephonic (audio-only, KX modifier) also allowed, but ONLY when the caregiver's physical/behavioral health status or an access barrier (transportation, technology) prevents in-person or telehealth participation (CCP 8F §3.1.2 and Attachment A, eff. 8/1/2026). | GT (telehealth), KX (telephonic, caregiver-barrier criteria only) |
| 97158 | No — 97158 is not part of NC Medicaid's CCP 8F billable RB-BHT code set (97151–97157 only) | N/A | N/A per N/A | — | N/A | — |
| 0362T | No — 0362T is not part of NC Medicaid's CCP 8F billable RB-BHT code set (97151–97157 only) | N/A | N/A per N/A | — | N/A | — |
| 0373T | No — 0373T is not part of NC Medicaid's CCP 8F billable RB-BHT code set (97151–97157 only) | N/A | N/A per N/A | — | N/A | — |

Code notes:

- **97151:** Corrected 2026-10-18: Trillium’s Claims Billing Guide 2026 applies NCCI MUEs and denies claims that violate them, so the per-day ceiling is the CMS Medicaid MUE; the benefit plan itself sets no unit cap ("Units: One unit = 15 minutes"). Units run in 15-minute increments.
- **97155:** Corrected 2026-10-18: the per-day ceiling is the CMS Medicaid MUE that Trillium applies (Claims Billing Guide 2026). The earlier figure here — up to 1 hour per 10 hours of 97153/97154 — was inferred from Vaya’s pass-through rule and is not a Trillium rule; CCP 8F’s own ratio band is 10–20% of paraprofessional hours once they pass 200 in 180 days.
- **97158, 0362T, 0373T:** Confirmed absent from CCP 8F's own CPT code table (Attachment A), from Alliance's and Trillium's posted rate schedules, and from Vaya's authorization guidelines and rate schedule — checked directly, not assumed from the CPT list.

### Medicaid rates

Source: Trillium Health Resources — Rate Table FY 26-27 Effective 2025-10-01.

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | $30.56 | 15min | — |
| 97152 | $61.73 | 15min | — |
| 97153 | $20.81 | 15min | — |
| 97154 | $11.37 | 15min | — |
| 97155 | $32.22 | 15min | — |
| 97156 | $23.70 | 15min | — |
| 97157 | $11.51 | 15min | — |
| 97158 | N/A | N/A — not part of NC’s CCP 8F billable code set | — |
| 0362T | N/A | N/A — not part of NC’s CCP 8F billable code set | — |
| 0373T | N/A | N/A — not part of NC’s CCP 8F billable code set | — |

### Contacts

- **Provider services phone:** 866-998-2597
- **Phone menu path:** Listed as "Business & Administrative Matters" in the Claims Submission Protocol's Tailored Plan Medicaid contact block; "Member & Recipient Services" (877-685-2415) is the separate member-facing line — do not use it for provider calls.
- **Portal:** [Trillium iTransact (Tailored Plan claims, authorizations and eligibility from 10/1/2026; Medicaid Direct stays on Provider Direct)](https://provider.trilliumitransact.com/)

Questions to ask on a verification call:

- Is our iTransact access (system administrator, Vendor ID and access code from the onboarding email) active, and does a 270 sent to payer ID 43072 return RB-BHT benefit detail in real time or batch?
- What are Trillium's per-code unit caps for 97151-97157, beyond the 180-day TAR cycle?
- Is there a copay or coinsurance for RB-BHT, and if so is it per-visit or per-day?
- Does the deductible apply to RB-BHT, and is there an out-of-pocket max?
- What STC bucket does Trillium return ABA benefit detail under on a 270/271 eligibility response?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23)
- https://www.trilliumhealthresources.org/sites/default/files/docs/Provider-documents/Claims/Trillium-Unified-Claims-Platform-Questions-Answer.pdf (accessed 2026-10-07)
- https://www.trilliumhealthresources.org/sites/default/files/docs/Provider-documents/Claims/Trillium-Medicaid-Direct-Tailored-Plan-Claims-Submission-Protocol.pdf (accessed 2026-10-07)
- https://www.trilliumhealthresources.org/sites/default/files/docs/Benefit-Plans-Services-Definitions/Trillium-Medicaid-Child-BH-Benefit-Plan.pdf (accessed 2026-09-27)
- https://www.nctracks.nc.gov/content/dam/jcr:b987d9f5-d230-4c81-b78b-05780eb0bbaf/270_271%20Health%20Care%20Eligibility%20Benefit%20Inquiry%20and%20Response%20(7).pdf (accessed 2026-07-23)
- https://medicaid.ncdhhs.gov/8f-research-based-behavioral-health-treatment-rb-bht-autism-spectrum-disorder-asd/open (accessed 2026-09-01)
- https://medicaid.ncdhhs.gov/documents/files/8f-1/open (accessed 2026-07-23)
- https://www.trilliumhealthresources.org/sites/default/files/docs/Provider-documents/Claims/Trillium-Claims-Billing-Guide.pdf (accessed 2026-10-18)
- https://www.cms.gov/files/zip/medicaid-ncci-2026-q4-mue-edits-practitioner-services.zip (accessed 2026-10-18)
- https://medicaid.ncdhhs.gov/health-plan-billing-guide-version-36/download?attachment= (accessed 2026-10-18)
- https://www.alliancehealthplan.org/document-library/97251 (accessed 2026-09-27)
- https://www.trilliumhealthresources.org/sites/default/files/docs/Billing-Codes-Rates/Trillium-Rate-Table-FY-26-27.pdf (accessed 2026-07-23)
- https://providers.vayahealth.com/wp-content/uploads/2025/09/Authorization_Guidelines_Medicaid_RB_BHT_ASD.pdf (accessed 2026-07-23)

## Common questions

### Does Trillium cover ABA therapy?

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).

### Does Trillium cover ABA for adults?

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.

### Does Trillium restrict ABA in school?

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.

### Is Trillium's ABA network open?

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.

### Can Trillium ABA services be delivered by telehealth?

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.

### What happens to the authorization when switching ABA agencies on Trillium?

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.

### Can an out-of-state BCBA treat Trillium members in North Carolina, including by telehealth?

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)).

### Can Trillium authorize ABA retroactively?

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.

### Does Trillium Medicaid have a timely filing window?

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.

### What Vendor ID and access code do I need to set up Trillium’s iTransact platform?

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.

### What payer ID do I use for Trillium Tailored Plan ABA claims?

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.

### Does Trillium require taxonomy on the claim?

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.

## Primary sources

1. [NC Medicaid — Federal Regulation Guidelines for Ordering, Prescribing or Referring (OPR) Providers (modified 7/1/2026)](https://medicaid.ncdhhs.gov/providers/claims-and-billing/federal-regulation-guidelines-ordering-prescribing-or-referring-opr-providers)
2. [NC Medicaid — Managed Care Billing Guidance to Health Plans v36 (9/4/2026)](https://medicaid.ncdhhs.gov/health-plan-billing-guide-version-36/download?attachment=)
3. [CMS — Medicaid NCCI MUE table, practitioner services (effective 10/1/2026–12/31/2026)](https://www.cms.gov/files/zip/medicaid-ncci-2026-q4-mue-edits-practitioner-services.zip)
4. [Trillium — Medicaid Child BH Services Benefit Plan](https://www.trilliumhealthresources.org/sites/default/files/docs/Benefit-Plans-Services-Definitions/Trillium-Medicaid-Child-BH-Benefit-Plan.pdf)
5. [NC Medicaid — Clinical Coverage Policy 8F](https://medicaid.ncdhhs.gov/8f-research-based-behavioral-health-treatment-rb-bht-autism-spectrum-disorder-asd/open)
6. [NC Medicaid — Updated reminder: RB-BHT service delivery requirements (8/31/2026)](https://medicaid.ncdhhs.gov/blog/2026/08/31/updated-reminder-requirements-research-based-behavioral-health-treatment-service-delivery-aug-31)
7. [Trillium Health Resources — Provider Communication 005 (July 9, 2026): Mandatory Closed Network for Peer Support and RB-BHT Services](https://www.trilliumhealthresources.org/article/provider-communication-005)
8. [Session Law 2026-41 (S.B. 257, Current Operations Appropriations Act of 2026, approved 7/7/2026), §9E.22](https://www.ncleg.gov/EnactedLegislation/SessionLaws/PDF/2025-2026/SL2026-41.pdf)
9. [N.C.G.S. Chapter 90, Article 43 — behavior analyst licensure (G.S. 90-740, 90-741, 90-745, 90-746)](https://www.ncleg.gov/EnactedLegislation/Statutes/HTML/ByArticle/Chapter_90/Article_43.html)
10. [Session Law 2026-1 (H.B. 696), §3C.18(c) — new G.S. 108C-9(e): no out-of-state Medicaid enrollment for BCBAs/QASP supervisors](https://www.ncleg.gov/EnactedLegislation/SessionLaws/PDF/2025-2026/SL2026-1.pdf)
11. [eCFR — 42 CFR 438.602(b)(1): the state must screen and enroll all managed care network providers](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-H/section-438.602)
12. [Trillium Health Resources — Claims Billing Guide 2026](https://www.trilliumhealthresources.org/sites/default/files/docs/Provider-documents/Claims/Trillium-Claims-Billing-Guide.pdf)
13. [Trillium Health Resources — Unified Claims System Provider FAQ (revised 9/30/2026)](https://www.trilliumhealthresources.org/sites/default/files/docs/Provider-documents/Claims/Trillium-Unified-Claims-Platform-Questions-Answer.pdf)
14. [Trillium Health Resources — Claims Submission Guidelines (effective 10/1/2026)](https://www.trilliumhealthresources.org/sites/default/files/docs/Provider-documents/Claims/Trillium-Medicaid-Direct-Tailored-Plan-Claims-Submission-Protocol.pdf)
15. [Trillium Health Resources — Special announcement: Onboarding into the Trillium Provider Claims System (8/5/2026)](https://www.trilliumhealthresources.org/sites/default/files/docs/Special-Announcement-Providers/080526-Onboarding-Trillium-Provider-Claims.pdf)
16. [NC Medicaid Managed Care Provider Playbook — Prompt Payment fact sheet (Standard Plans, NC Medicaid Direct, Tailored Plans)](https://medicaid.ncdhhs.gov/provider-playbook-prompt-payment-fact-sheet/download)
17. [Trillium Health Resources — Urgent Notifications for network providers (notice archive)](https://www.trilliumhealthresources.org/for-providers/provider-communications/urgent-notification)
18. [Trillium Health Resources — Tailored Plan Provider Manual](https://www.trilliumhealthresources.org/sites/default/files/docs/Provider-documents/Provider-Manual/Trillium-TP-Provider-Manual.pdf)
19. [42 CFR 438.210(d) — Medicaid managed care authorization decision timeframes](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-D/section-438.210)
20. [TRICARE — Using Other Health Insurance (updated 10/17/2025)](https://www.tricare.mil/Plans/OHI)
21. [VA — CHAMPVA Guidebook (updated 1/1/2025), CHAMPVA as secondary payer](https://www.va.gov/files/2025-12/CHAMPVA-Guidebook.pdf)

Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed 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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.