WellCare of North Carolina: merged into Carolina Complete Health (4/1/2026).

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.^[9][8]

Historical. WNC.CP.109 mirrored the state rule — a validated diagnostic tool, and a provisional diagnosis under age three with a definitive diagnosis within six months. WellCare of North Carolina merged into Carolina Complete Health effective April 1, 2026, so the operative rule for these members is now the state rule as administered by Carolina Complete Health.^[9][8][8][7]

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.^[9][8]

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).^[9][8]

Follows the NC Medicaid rule: a service order signed and dated by a Licensed MD, DO or Licensed Psychologist, in place on or before the first date of service, based on a behavioral/adaptive/functional assessment and treatment plan, valid one year and re-ordered annually. 97151 and 97152 need no service order for prior approval; 97153–97157 do.^[9][8]

Historical. WellCare governed RB-BHT telehealth through a separate policy, WNC.CP.193, allowing telephonic parent training only for documented caregiver health or access barriers. The state’s finalized CCP 8F (eff. 8/1/2026) now controls statewide: telehealth removed entirely for 97152, 97153 and 97154, 97155 capped at 50% of billing per beneficiary per 180 days, 97151 telehealth eligible with clinical justification, and 97156/97157 keeping the KX telephonic caregiver-barrier exception. WellCare of NC merged into Carolina Complete Health on April 1, 2026. NC Medicaid’s billing guidance binds every health plan, including Carolina Complete Health for former WellCare members, 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.^{[9][8][8][7][5]}

WellCare of NC merged into Carolina Complete Health on April 1, 2026, and CCH’s rules govern dates of service from then on (standard 14 calendar days per its manual, which dates the 7-day change to January 1, 2027, against a federal 7-calendar-day ceiling that reaches NC plans from July 1, 2026; expedited 72 hours). For pre-merger dates of service, WellCare’s last manual said standard pre-service decisions "will not exceed 14 (14) calendar days" with a 14-day extension, expedited 72 hours, urgent concurrent 24 hours, and post-service 30 calendar days. CCP 8F requires the reauth before the current authorization expires; active WellCare authorizations transferred to CCH.^{[7][15][4][16][9]}

For dates of service from April 1, 2026, bill Carolina Complete Health, which pays last: the other insurer first, then CCH with its EOB/EOP or rejection letter, within 365 calendar days of the primary EOB/RA date. For pre-merger claims, WellCare’s manual required "Any balance due after receipt of payment from the primary payer" to be submitted "with a copy of the primary payer's explanation of payment (EOP)", within 90 days of the primary EOB date, paid on lesser-of logic. Neither manual says whether the plan’s own PA is needed when it pays second; CCP 8F requires prior approval before rendering RB-BHT with no exception for other insurance. Under federal rules TRICARE pays before Medicaid and CHAMPVA pays first when the child is also Medicaid-eligible.^{[7][2][4][9][17][18]}

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 WellCare’s last manual caps how many paraprofessionals one LQASP may supervise; the limits are the per-beneficiary 10% floor and 10–20% band.^[9][8]

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.^[9][8]

Two different ceilings. Per day, a claim edit: NC Medicaid applies the CMS Medicaid National Correct Coding Initiative to professional claims, including Medically Unlikely Edits — units-of-service edits that define for each CPT or HCPCS code "the number of units of service that is unlikely to be correct" — and its billing guidance tells every health plan to apply NCCI and MUE edits as well (§3.6.2). WellCare’s last NC manual (eff. 1/22/2026, before the merger into Carolina Complete Health) ran claims through editing software that incorporates CMS guidelines "including, but not limited to, the National Correct Coding Initiative (NCCI)". The public CMS Medicaid NCCI practitioner MUE table for dates of service 10/1–12/31/2026 sets these maxima per beneficiary per date of service: 97151 32 units, 97152 16, 97153 32 (8 hours), 97154 18, 97155 24, 97156 16, 97157 16, 97158 16, 0362T 16 and 0373T 32. Units above the MUE on one date of service deny as a claim edit whatever the authorization allows; the authorization, not the MUE, is the real weekly limit. Per authorization period, the NC Medicaid rule (CCP 8F sets no per-day cap of its own): plans at or under 16 hours a week run 180-day initial and reauthorization cycles; plans above 16 hours a week run 90-day cycles. Within a 180-day period, 97155 telehealth is capped at 50% of 97155 billing and at least six caregiver training sessions are required. Educational-setting and IEP hours are excluded from the treatment-hour calculation.^{[9][5][6][4][8]}

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.^[9][8]

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.^[9][8]

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.^[9][8]