---
title: Vaya Health ABA coverage (NC Tailored Plan).
url: "https://carelu.com/payers/vaya-health"
markdown_url: "https://carelu.com/payers/vaya-health.md"
state: NC (North Carolina)
payer: Vaya Health (NC Tailored Plan)
kind: Medicaid managed care plan (MCO)
parent_program: North Carolina Medicaid
description: "How Vaya Health (Vaya Total Care) administers NC Medicaid RB-BHT (ABA) in western North Carolina — CCP 8F administration through SARs to Vaya UM, and which plan documents to pull from the provider portal."
last_reviewed: October 2026
vob_data_updated: 2026-10-15
---

# Vaya Health ABA coverage (NC Tailored Plan).

_Payer Guide · Vaya Health (NC) · Last updated October 2026 · 18 primary sources_

> Western-NC Tailored Plan, now Vaya Partners (merged with Partners 10/1/2026); 8F via SARs in ProviderCONNECT — key documents must be pulled manually.

Vaya Health — operating the "Vaya Total Care" Tailored Plan across western North Carolina — administers RB-BHT as straight CCP 8F, with authorization running through service authorization requests (SARs) to Vaya's in-house UM team. Its provider-document library previously blocked automated access; as of this review its authorization guidelines are readable directly, and the code-level passthrough thresholds below are confirmed from Vaya's own document text rather than inferred.

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 — per 8F; Vaya publishes RB-BHT authorization guidelines (v2.0, eff. 9/2025) on its provider portal [10][7]
- **Prior auth for treatment**: Required — service authorization requests (SARs) reviewed by Vaya UM against 8F medical necessity [7][10]
- **Autism diagnosis required?**: Yes — ASD via a validated diagnostic tool; under-3s may start on a provisional diagnosis [10]

## At a glance

- **Plan type:** NC Tailored Plan (public LME/MCO) — Vaya Partners since the October 1, 2026 merger of Vaya Health and Partners Health Management
- **Clinical rules:** CCP 8F; Vaya RB-BHT authorization guidelines v2.0 (eff. 9/2025)
- **Prior auth:** Required — SARs to Vaya UM
- **UM contact:** (800) 893-6246 ext. 1515 (behavioral health) · UM@VayaPartners.org
- **Portal:** ProviderCONNECT — providers.vayapartners.org/portal
- **Rates:** ≥100% of the NC Medicaid fee schedule (state floor); Vaya publishes its own rate schedule

## Vaya Health is now Vaya Partners (October 1, 2026)

Vaya's provider site now opens with: "Vaya Health and Partners Health Management officially merged on October 1, 2026, to become Vaya Partners," and calls providers.vayahealth.com "a legacy website" where "certain forms and resources may remain available" during the transition. NCDHHS's LME/MCO directory now lists three Tailored Plans: Alliance Health, Trillium Health Resources and Vaya Partners. [19][9][4][20][21]

What changed for an ABA provider: SARs now go "electronically through the Vaya Partners ProviderCONNECT" portal, and the binding rulebook is the Vaya Partners Provider Operations Manual v1.0 (Oct. 1, 2026), which replaces Vaya's manual v3.1 (March 2026). Its UM contact is UM@VayaPartners.org or 1-800-893-6246, ext. 1515 (behavioral health); provider support is 1-866-990-9712. The RB-BHT rules below that come from Vaya's own authorization guidelines still apply: Vaya Partners' Authorization Guidelines page still links Vaya's RB-BHT guidelines (v2.0). [19][9][4][20][21]

## How Vaya administers RB-BHT

The clinical picture is the CCP 8F baseline: PA on all services including the 97151 comprehensive assessment (which Vaya's guidelines designate as LQASP-billed), authorization cycles tiered by intensity (180 calendar days at ≤16 hrs/week, 90 days above), and LQASP treatment-plan reviews. SARs submit through the provider portal and are reviewed by Vaya UM against medical necessity and the clinical coverage policy. [10][7][8][5]

Vaya's "Authorization Guidelines: Medicaid RB-BHT Services for ASD" (v2.0, rev. 9/5/2025 — still current, no v2.1/2026 update found) sets specific passthrough thresholds worth building into intake: 97151 assessment requests up to 32 units per six months go through as notification-only, without a full SAR, while requests above 32 units need a complete SAR (service order, treatment plan, MD/DO/psychologist-validated ASD diagnosis). 97155 (protocol modification by a BCBA-LP) similarly passes through on notification alone up to a 1-hour-per-10-hours ratio against direct intervention (97153/97154); above that ratio it needs a full SAR for medical-necessity review. All other codes (97152, 97153, 97154, 97156, 97157) require a SAR plus FBA, treatment plan, and service order on both initial and concurrent requests. A companion document, "RB-BHT Guidance" (v1.0, rev. 5/1/2025), restates the CCP 8F service definitions and clarifies "Program Modification vs. Supervision" for 97155. [10][7][8][5]

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. [10][7][8][5]

## Is Vaya Health's ABA network open or closed?

Closed since July 7, 2026. Vaya's Provider Communication Bulletin of July 8, 2026: as directed by S.L. 2026-41, Vaya "will transition Research-based Behavioral Health Treatment (RB-BHT) and Peer Support Services (PSS) to closed network services. Effective July 7, 2026, only contracted providers within the approved closed network may deliver RB-BHT and PSS." [4][11][12]

Providers already delivering RB-BHT "should continue operating as contracted and approved." New providers can still ask: "Vaya will evaluate new requests to provide RB-BHT and PSS on a case-by-case basis against our selection criteria, which includes a network need." Questions go to provider.info@vayahealth.com. [4][11][12]

The merged plan keeps it closed: the Vaya Partners Provider Operations Manual (v1.0, Oct. 1, 2026) lists "Research-based Behavioral Health Treatment (RB-BHT)" among the services for which it maintains a closed network, and new closed-network applicants must show "a need for the service the applicant is seeking to provide." Provider questions now go to ProviderInfo@VayaPartners.org. [4][11][12]

## 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. [13][14][15][16]

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. [13][14][15][16]

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 Vaya Health’s network has to be enrolled with NC Medicaid as well. [13][14][15][16]

## Can Vaya Health 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. [10][4][9]

Vaya Partners allows it only for late eligibility. Its manual (v1.0, Oct. 1, 2026): "If a member did not have Medicaid at the time the service was provided but later gains eligibility that covers the dates of service, providers may request retrospective authorization by submitting the SAR and all documentation no later than 90 days following the notification of the Medicaid eligibility determination." Its prior-authorization page adds: "Except for requests based on retrospective Medicaid eligibility, all SARs must have a service start date that is on or after the date of SAR submission." [10][4][9]

## What is Vaya Health’s timely filing limit and claim payment turnaround?

NC Medicaid sets the floor for every Tailored Plan and LME/MCO, Vaya Health included, and the Vaya Partners manual (v1.0, Oct. 1, 2026) repeats it: Medicaid claims within 365 days of the date of service or discharge, State-funded claims within 90 days, and claims where Vaya Partners pays last within 180 days of the other payer's remittance. Its prompt-payment fact sheet gives Tailored Plans a 365-day timely filing window from July 1, 2024. NC Medicaid Direct claims the LME/MCOs process also moved from 90 to 365 days on July 1, 2024. The window covers the original claim and any corrected claim. State-funded services must be filed within 90 calendar days. [17][4][3][2][5][1]

Within 18 calendar days of receiving a medical claim the plan must say whether it is clean or pend it for more information. It must pay or deny a clean claim within 30 days, and deny the claim if requested information has not arrived within 90 days. Late payment carries 18% annual interest. [17][4][3][2][5][1]

Weekly cutoff: “Vaya Partners adheres to the standardized LME/MCO checkwrite schedule, which is based on a 5 p.m. Tuesday cutoff. Claims received before this cutoff date will be paid the following week according to the checkwrite schedule.” In the 2026 schedule (rev. 9/30/2026), claims posted Wednesday through Tuesday go into a check run the following Monday, with payment dated that Thursday. For example, claims posted 1/28–2/3/2026 ran on 2/9 and were paid 2/12. Holiday weeks shift by a day. The manual encourages providers to bill “on a weekly or bimonthly schedule” to match it. [17][4][3][2][5][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). [17][4][3][2][5][1]

Taxonomy: the plan must “validate the taxonomy code submitted on the claim” against the provider’s NC Medicaid enrollment record and “price claims based on the taxonomy code submitted on the claim” (billing guidance §3.22), so bill the taxonomy you are enrolled under in NCTracks. The Vaya Partners manual: “Accurate NPI numbers and taxonomy codes are required for claims to be accepted and processed,” and they must “exactly match the information in NCTracks,” or the claim is denied or recouped. [17][4][3][2][5][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). [17][4][3][2][5][1]

## Intake gates

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

- **Age limit**: Follows the NC Medicaid rule: CCP 8F carries no upper age bound (the 8/1/2026 rewrite removed "under 21 years of age" from the eligibility provision), under-21 members carry the EPSDT special provision, and beneficiaries under three may start on a provisional diagnosis. [10][7]
- **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. [10][7]
- **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. [10][7]
- **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). [10][7]
- **Referral required?**: Follows the NC Medicaid rule (MD/DO/Licensed Psychologist service order, assessment-based, dated on or before the start, valid one year), with Vaya-specific passthrough thresholds that decide whether a full service authorization request is needed: 97151 up to 32 units per six months passes through on notification alone, and above that needs a complete SAR carrying the service order, treatment plan and MD/DO/psychologist-validated ASD diagnosis. 97152, 97153, 97154, 97156 and 97157 always need a SAR with FBA, treatment plan and service order on both initial and concurrent requests. [10][7][7]
- **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. [10][7][5]
- **Prior-auth decision time**: Vaya Partners (manual v1.0, effective Oct. 1, 2026): "For standard reviews, Vaya Partners will issue a decision within seven (7) calendar days," extendable "up to fourteen (14) additional days," and requests meeting expedited criteria are reviewed "within 72 hours." Lead time: submit a SAR "at least seven (7) calendar days prior to the requested service start date," and a concurrent request "seven (7) calendar days prior to the end of the current authorization." When UM asks for more information, "Providers have up to one business day to submit any requested additional information" — incomplete SARs are returned "unable to process." This replaces Vaya Health's March 2026 manual (14 calendar days to decide, 14 days' lead time, three business days for missing information). RB-BHT authorizations run 180 days at 16 hours a week or fewer, 90 above (CCP 8F). [4][9][22][23]
- **Other insurance (who pays first)**: Vaya Partners (manual v1.0, Oct. 1, 2026): "Medicaid is the payor of last resort." Collect all first- and third-party funds before billing Vaya Partners, wait a reasonable time for the other payer, keep its RA/EOB or other proof of payment or denial, and bill Vaya Partners only the remaining amount; such claims are due "within 180 days of the date you receive a remittance from a first- or second-party payor." Where the member also uses state-funded services, state funds pay last. The manual does not say whether its own prior authorization is still needed when it pays second; CCP 8F requires prior approval before rendering RB-BHT and carves out no exception for members with other insurance, so get the plan’s authorization on file unless the plan confirms in writing that it is waived. Under federal rules TRICARE pays before Medicaid and CHAMPVA pays first when the child is also Medicaid-eligible. [4][10][24][25]

## Delivery and billing rules

Coverage decides whether Vaya Health (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 (10% LQASP observation floor; 10–20% LQASP-to-paraprofessional ratio above 200 paraprofessional hours per 180 days). Vaya adds an authorization threshold on top: 97155 protocol modification by a BCBA-LP passes through on notification alone up to a ratio of one hour per ten hours of direct intervention (97153/97154); above that ratio it needs a full SAR for medical-necessity review. Neither CCP 8F nor the Vaya Partners manual (v1.0) caps how many paraprofessionals one LQASP may supervise; the limits are the per-beneficiary 10% floor and 10–20% band. [10][7][7]
- **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. [10][7]
- **Daily limits / MUEs**: Two different ceilings. Per day, a claim edit: the Vaya Partners Provider Operations Manual (v1.0, Oct. 1, 2026) says Vaya Partners "uses National Correct Coding Initiative (NCCI) edits and Medically Unlikely Edits (MUE) during adjudication to validate claims," as NC Medicaid’s billing guidance requires of every health plan (§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 NC Medicaid rule (CCP 8F sets no per-day cap of its own). Vaya’s own thresholds are the practical ones at intake: 97151 up to 32 units per six months and 97155 up to a 1-hour-per-10-hours ratio against direct intervention pass through on notification, and anything above either needs a full SAR. [10][7][4][5][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. [10][7]
- **Place of service**: Follows the NC Medicaid rule: clinic, home, school and community settings are all payable in any combination, individually justified and documented in the treatment plan, with the goal of advancing toward natural settings. IDEA-duplicative school services are excluded, and telehealth or telephonic claims carry the provider’s usual place-of-service code. [10][7]
- **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. [10][7]

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

- **Member county:** Vaya's footprint is western NC — confirm the county maps to Vaya before intake.
- **ASD diagnosis + validated tool:** Per CCP 8F, with the MD/DO/LP service order.
- **Unit thresholds:** 97151 ≤32 units/6mo and 97155 ≤1hr-per-10hrs ratio pass through on notification only — above either, a full SAR is required.

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

## Verification of benefits (VOB) data

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

### EDI routing

- **Behavioral health administrator:** none
- **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 | Passthrough: notification SAR + service order, up to 32 units per 6 months; requests above 32 units reviewed for medical necessity. Above 32 units, Initial/Concurrent SAR + service order + clinical documentation validating ASD diagnosis via a scientifically validated tool required. | 32 units per 6 months (passthrough notification threshold; higher requests reviewed) 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 | Initial: SAR + FBA + treatment plan + service order (annual) + clinical documentation validating ASD diagnosis. Concurrent: SAR + FBA + treatment plan + service order (annual). | 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 | Initial: SAR + FBA + treatment plan + service order (annual) + clinical documentation validating ASD diagnosis. Concurrent: SAR + FBA + treatment plan + service order (annual). | 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 | Initial: SAR + FBA + treatment plan + service order (annual) + clinical documentation validating ASD diagnosis. Concurrent: SAR + FBA + treatment plan + service order (annual). | 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 | Passthrough: notification SAR, up to 1 hour per 10 hours of direct intervention (97153/97154) — i.e. 10%. Requests for a higher ratio: SAR + service order + clinical documentation validating ASD diagnosis + FBA + treatment plan, reviewed for medical necessity. | 1 hour per 10 hours of 97153/97154 (10% passthrough threshold; higher ratios reviewed) 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 | Initial: SAR + FBA + treatment plan + service order (annual) + clinical documentation validating ASD diagnosis. Concurrent: SAR + FBA + treatment plan + service order (annual). | 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 | Initial: SAR + FBA + treatment plan + service order (annual) + clinical documentation validating ASD diagnosis. Concurrent: SAR + FBA + treatment plan + service order (annual). | 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:

- **97153:** Vaya's guidelines list this as "97153 96" — modifier 96 (habilitative) appears alongside the base code in its documentation table.
- **97154:** Vaya's guidelines list this as "97154 96" — modifier 96 (habilitative) appears alongside the base code.
- **97155:** Confirmed by two independent Vaya documents (Authorization Guidelines v2.0 and the May-2025 RB-BHT Guidance) and consistent with the May-2019 NC Medicaid Bulletin restriction that 97155 does not cover routine technician-supervision/fidelity checks.
- **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: Vaya Health — Standard Rate Schedule: Tailored Plan/Medicaid Direct (Non-Clinician), dated 8/1/2024 Effective 2024-07-01.

| 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 | — |
| 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

- **Benefits by phone:** Yes
- **Provider services phone:** 1-866-990-9712
- **Phone menu path:** General Provider Support Service Line is 1-866-990-9712. Code-specific Authorizations (behavioral health) route to 1-800-893-6246 ext. 1515; Provider Portal/IT technical assistance is ext. 1500.
- **Hours:** 7 a.m.–6 p.m., Monday–Saturday, including holidays
- **Portal:** [Vaya Provider Portal](https://providers.vayahealth.com/provider-portal/)

Questions to ask on a verification call:

- What is Vaya's payer ID for 270/271 real-time eligibility checks — only Office Ally's 13010 is confirmed; Vaya does not appear on pVerify or Availity's national lists?
- What are the per-code unit caps for 97152, 97153, 97154, 97156, and 97157 (97151's 32-units/6-months and 97155's 10% passthrough are already confirmed)?
- 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 Vaya 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://cms.officeally.com/OfficeAlly/Forms/EDI/VayaHealth_SmokyMtn_EDI_ENR_PKT.pdf (accessed 2026-07-23)
- 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://providers.vayahealth.com/wp-content/uploads/2025/09/Authorization_Guidelines_Medicaid_RB_BHT_ASD.pdf (accessed 2026-07-23)
- https://providers.vayahealth.com/wp-content/uploads/2025/05/RB_BHT_Guidance_20250522.pdf (accessed 2026-07-23)
- 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/2024/07/Standard_Rate_Schedule_Tailored-Plan-Medicaid-Direct_Non-Clinician_20240801.pdf (accessed 2026-07-23; source document older than 18 months)
- https://providers.vayahealth.com/contact/ (accessed 2026-07-23)
- https://providers.vayahealth.com/wp-content/uploads/2025/07/Provider_Operations_Manual_3.0_DRAFT.pdf (accessed 2026-10-14)

## Common questions

### Does Vaya Health cover ABA therapy?

Yes — as a Tailored Plan, Vaya administers RB-BHT under CCP 8F, with service authorization requests reviewed by its UM team. Since the October 1, 2026 merger with Partners Health Management it operates as Vaya Partners: submit SARs in ProviderCONNECT; UM is (800) 893-6246 ext. 1515 (behavioral health) or UM@VayaPartners.org.

### Does every Vaya ABA request need a full SAR?

No — 97151 assessment requests up to 32 units per 6 months and 97155 up to a 1-hour-per-10-hours ratio against direct intervention pass through on notification alone. Above either threshold, a complete SAR (service order, treatment plan, validated diagnosis) is required.

### Is Vaya Health accepting new ABA providers?

Closed since July 7, 2026. Vaya says only contracted providers in its approved closed network may deliver RB-BHT; current providers continue as contracted, and new requests are reviewed case by case against selection criteria that include network need. Email provider.info@vayahealth.com.

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

Vaya Health applies CCP 8F, which does not say an authorization transfers. CCP 8F treats needing "a different RB-BHT provider agency" as a transition or discharge reason, requires the Treatment Plan to be reviewed on a change in service provider, and will not pay two providers for duplicate services. Expect the new agency to submit its own request, and confirm with Vaya Health utilization management.

### Can an out-of-state BCBA treat Vaya Health 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 Vaya Health authorize ABA retroactively?

Only for retroactive Medicaid eligibility: Vaya Partners takes a retrospective SAR with all documentation no later than 90 days after the eligibility determination notice. Otherwise every SAR must start on or after the date it is submitted.

### What is Vaya Health’s timely filing limit for ABA claims?

365 days from the date of service for Tailored Plan and NC Medicaid Direct claims since July 1, 2024, corrected claims included, under NC Medicaid’s rule for LME/MCOs. State-funded services are 90 days. Clean claims must be paid or denied within 30 days.

## 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. [Vaya Partners — 2026 Checkwrite Schedule (rev. 9/30/2026)](https://resources.vayapartners.org/2026-checkwrite-schedule/)
3. [Vaya Partners — Rate and Checkwrite Schedules (ProviderCENTRAL): 5 p.m. Tuesday cutoff](https://providers.vayapartners.org/rate-checkwrite-schedules/)
4. [Vaya Partners — Provider Operations Manual v1.0 (Oct. 1, 2026)](https://resources.vayapartners.org/wp-content/uploads/Vaya_Partners_Provider_Operations_Manual_1.0_20261001.pdf)
5. [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=)
6. [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)
7. [Vaya Health — Authorization Guidelines: Medicaid RB-BHT Services for ASD (v2.0, rev. 9/5/2025)](https://providers.vayahealth.com/wp-content/uploads/2025/09/Authorization_Guidelines_Medicaid_RB_BHT_ASD.pdf)
8. [Vaya Health — RB-BHT Guidance (v1.0, rev. 5/1/2025)](https://providers.vayahealth.com/wp-content/uploads/2025/05/RB_BHT_Guidance_20250522.pdf)
9. [Vaya Partners — Prior Authorization (ProviderCENTRAL; replaces the retired providers.vayahealth.com page, checked 10/18/2026)](https://providers.vayapartners.org/prior-authorization/)
10. [NC Medicaid — Clinical Coverage Policy 8F](https://medicaid.ncdhhs.gov/8f-research-based-behavioral-health-treatment-rb-bht-autism-spectrum-disorder-asd/open)
11. [Vaya Health — Provider Communication Bulletin, Issue 3 (July 8, 2026): Important Changes to RB-BHT and Peer Support Services](https://providers.vayahealth.com/wp-content/uploads/2026/07/PCB_Issue_3_20260708.pdf)
12. [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)
13. [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)
14. [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)
15. [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)
16. [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)
17. [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)
18. [Vaya Partners — Provider Communication Bulletin archive](https://providers.vayapartners.org/bulletins/)
19. [Vaya Partners — ProviderCENTRAL home (merger notice)](https://providers.vayapartners.org/)
20. [Vaya Partners — Authorization Guidelines page (still links Vaya RB-BHT guidelines v2.0)](https://providers.vayapartners.org/authorization-guidelines/)
21. [NCDHHS — LME/MCO directory (Alliance, Trillium, Vaya Partners)](https://www.ncdhhs.gov/providers/lme-mco-directory)
22. [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)
23. [NC Medicaid Standard Plan contract, Amendment 17(18) — "Rating Period" defined as July 1 to June 30](https://medicaid.ncdhhs.gov/contract-30-190029-dhb-prepaid-health-plan-services-amendment-1718/open)
24. [TRICARE — Using Other Health Insurance (updated 10/17/2025)](https://www.tricare.mil/Plans/OHI)
25. [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.