Provider Communication 009

Residential Treatment Providers Site Level Changes

In Provider Communication Bulletin 008, it was communicated that Trillium Health Resources will transition all residential treatment provider authorizations to the main provider site in its new software platform beginning October 1, 2026. For NC Medicaid Direct members transitioning will occur on September 1, 2026.

Trillium will end date the site level (where the member resides) locations and associated service codes in Provider Direct on September 1, 2026. Going forward, any Treatment Authorization Requests (TARs) should be completed using the billing/office location only. All existing authorizations for affected services—including AFL, Respite, TFC, IAFT, CLFS, and related supports—will be moved, and new requests must be submitted at the provider’s main site. TFC providers may stop submitting Additional Site Request forms on September 1, while AFL and Respite providers must continue submitting them as usual. As a reminder, Alternative Family Living and Respite providers should continue submitting the Additional Site Request Form as they currently do. This ensures that the required site review can be completed and the Home and Community Based Services assessment can be approved. Effective September 1, 2026, Therapeutic Foster Care (TFC) and Intensive Alternative Family Treatment (IAFT) providers may discontinue submitting the Additional Site Form.

Updated Reminder: Requirements for Research-Based Behavioral Health Treatment Service Delivery – Aug. 31, 2026

This bulletin reflects revised effective dates and applies to all research based behavioral health treatment providers in NC Medicaid Managed Care and NC Medicaid Direct. 

This bulletin applies to NC Medicaid Direct and NC Medicaid Managed Care. 

This bulletin clarifies and emphasizes key requirements under the Clinical Coverage Policy (CCP) 8F, Research-Based Behavioral Health Treatment (RH-BHT) Services.

RB-BHT CCP 8F Changes Effective Aug. 1, 2026

NC Medicaid recently published an updated version of CCP 8F, effective Aug. 1, 2026. Providers are encouraged to review the updated policy for awareness of the new policy requirements. 

Key changes implemented in the policy which impact RB-BHT providers are:

• Requirements for existing and new paraprofessionals providing RB-BHT services to obtain at least one qualifying certification in order for services provided to Medicaid beneficiaries to be reimbursed.
  • Qualifying certifications are:
    • The Registered Behavior Technician (RBT) certification from the Behavior Analyst Certification Board (BACB); or 
    • The Applied Behavior Analysis Technician (ABAT) certification from the Qualified Applied Behavior Analysis Credentialing Board (QABA).
  • For existing paraprofessionals without a qualifying certification, the 120-day grace period starts on Aug. 1, 2026.
  • New paraprofessionals will be required to obtain a qualifying certification within 120 days of hire.
    • In order for services to be reimbursable, Paraprofessionals without a qualifying certification (RBT or ABAT) must receive supervision from a Licensed Qualified Autism Service Provider (LQASP) when services are provided during the grace period described in S.L. 2026-1 Section 3C.18.(a)(8). This supervision requirement for uncertified paraprofessionals shall remain in effect until the paraprofessional is fully certified. Ongoing supervision of paraprofessionals shall follow guidance per the accrediting body and CCP 8F. The LQASP assumes full professional responsibility for the paraprofessional’s work, including ensuring the quality of interventions, the safety of the client, and ongoing technician competency, as well as providing corrective guidance whenever errors occur. 
    • Claims billed for services delivered by non-certified paraprofessionals will not be reimbursed after the uncertified paraprofessional's 120-day grace period expires. Only fully certified staff may provide Medicaid-reimbursable RB-BHT services once the grace period expires.
    • Please note: Incidental supervision and training of the paraprofessional are not reimbursable. Also note, to bill 97155 all Clinical Coverage Policy and CPT code elements of 97155 must be met, including medical necessity for use of that code.
• Removal of telehealth for paraprofessional RB-BHT services (Current Procedural Terminology [CPT] codes 97152-97154).
• Requirements for RB-BHT treatment plans involving more than 16 hours of services per week to be reauthorized every three months. 
  • Providers do not need to take any action on existing authorizations; no actions will be taken to reduce the existing prior authorization (PA) duration. 
  • The new requirements for treatment plan durations will be enforced upon reauthorization.
  • All RB-BHT services count towards the 16 hours of services per week when determining the duration of an RB-BHT authorization.
• Requirements for service hour ratios for LQASP to Paraprofessional-delivered services, when paraprofessionals provided more than 200 hours of RB-BHT services over a six-month period.
• Requirements that at least 10% of all RB-BHT services provided by a paraprofessional involve the observation and direction of the paraprofessional by a LQASP.
• Updated requirements for treatment plans, diagnosis, and service documentation.

Covered RB-BHT Activities and Treatments

The RB-BHT benefit covers a range of autism spectrum disorder (ASD) treatment and intervention models, including but not limited to Applied Behavioral Analysis (ABA). Covered treatment and intervention models must be supported by credible scientific or clinical evidence as appropriate for preventing and minimizing disabilities and behavior challenges associated with ASD. In addition to ABA, examples of covered models include:

• Early Start Denver Model (ESDM)
• Play and Language for Autistic Youngsters (PLAY) Project
• Early Social Interaction (ESI) 
• Pivotal Response Training (PRT)
• Improving Parents as Communication Teachers (ImPACT)
• Joint Attention Symbolic Play Engagement and Regulation (JASPER)
• Enhanced Milieu Teaching (EMT)
• TEACCH/Structured Teaching

Activities and Treatments That Are Not Covered Under RB-BHT

The RB-BHT benefit does not cover treatments and interventions that are not supported by credible scientific or clinical evidence as being appropriate for ASD. Specific activities that are not covered by Medicaid under RB-BHT include:

• attending or participating in recreational activities, unless the activity is tied to a specific, medically necessary, therapeutic goal in an authorized treatment plan;
• nap time, break time or transportation to or from the RB-BHT site of service; 
• childcare services or services provided as a substitute for the parent or other individuals responsible for providing care and supervision to the beneficiary; 
• custodial, respite or personal care services; 
• teaching academic subjects or as a substitute for educational support personnel (e.g., teacher, teacher’s aide, paraprofessional/aide, academic tutor);
• services available through the Individuals with Disabilities Education Act (IDEA) or other educational programs that are duplicative of or supplant services identified in the beneficiary’s authorized treatment plan;
• staff-only meetings and training; or 
• administrative tasks and documentation.

Diagnosis Requirements

Beneficiaries receiving RB-BHT services must have received an ASD diagnosis from a licensed qualified provider as defined in the CCP. Diagnoses must be completed using clinically appropriate, scientifically validated tools. Diagnosing ASD must be within a provider’s license, training and experience, including being appropriately trained on the diagnostic tool(s) the provider uses. A provisional diagnosis is acceptable for beneficiaries younger than age 3. However, a final (non-provisional) diagnosis must be received within six months of the provisional diagnosis to maintain eligibility for RB-BHT.

Assessment Requirements

All beneficiaries must receive a behavioral, adaptive or functional assessment that is informed by the beneficiary’s developmental and medical history as well as all available and relevant supplementary information (e.g., interviews, chart reviews). Assessments should be completed using documented, clinically appropriate, scientifically validated tools. Please refer to CCP 8F for assessment tools which can be used.

Treatment Planning

All treatment plans must be based on an assessment that meets the assessment standards as defined in the CCP. All treatment plans must be person-centered, developmentally appropriate and individualized to the beneficiary’s strengths, functional impairments, adaptive skill levels and developmental profile. 

Treatment intensity (i.e., total weekly or monthly hours requested) must be individualized, medically necessary, and at a level that is scientifically demonstrated to be clinically effective at promoting adaptive functioning and preventing and minimizing disabilities associated with ASD. Treatment intensity and duration must not be in excess of the beneficiary’s needs.]

Treatment intensity should take into account all Medicaid-covered and non-Medicaid covered services the beneficiary receives or will receive on a regular/ongoing basis, not limited to services and supports for ASD and ASD-related symptoms (e.g., RB-BHT, school and school-based services, respite, occupational, physical and speech-language therapy, social skills training).

Excessive intensity and duration may be indicated by a beneficiary falling asleep during service delivery interventions. Reports of waking beneficiaries who have fallen asleep during treatment or forcing beneficiaries to stay awake in order to receive treatment may be interpreted as patient harm and prompt a provider investigation.

Provider Standards

All Licensed Qualified Autism Service Providers (LQASPs) and Certified Qualified Professionals (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 (S.L. 2026-1, 3C.18.(c)). This requirement is effective Aug. 2, 2026. 

Additionally, all RB-BHT services must be delivered by providers that meet the minimum standards described in the CCP as well as all relevant state licensure, certification, supervision and scope of practice standards. Paraprofessionals must carry out treatment interventions and activities in accordance with the beneficiary’s authorized treatment plan and under the supervision of a Licensed Qualified Autism Service Provider (LQASP) or Certified Qualified Professional (C-QP). Eligible providers (LQASP or C-QP) must directly observe paraprofessionals at a clinically appropriate frequency while they are providing direct treatment to ensure fidelity to treatment protocols in the treatment plan.

Administrative activities and incidental supervision completed to ensure the paraprofessional is adhering to the policies and procedures of their employer and certification standards are not billable.

Use of Telehealth

Reminder: The updated CCP 8F removes telehealth for paraprofessional RB-BHT services (CPT codes 97152-97154).

When allowed under the CCP, delivery of RB-BHT services via telehealth must be delivered safely, effectively and with consideration for the beneficiary’s and caregiver’s ability to participate. Telehealth may not be used solely for the convenience of the provider, beneficiary or the beneficiary’s caregiver. 

In addition, all services delivered via telehealth must be done in accordance with the guidelines in the CCP 1H: Telehealth, Virtual Patient Communications, and Remote Patient Monitoring, which can be found on the NC Medicaid Program Specific Policy page, including the following: 

• Providers must ensure that services can be safely and effectively delivered using telehealth, virtual communications or remote patient monitoring.
• Providers must consider a beneficiary’s behavioral, physical and cognitive abilities to participate in services provided using telehealth, virtual communications or remote patient monitoring.
• The beneficiary’s safety must be carefully considered for the complexity of the services provided.
• Beneficiaries are not required to seek services through telehealth, virtual communications or remote patient monitoring, and must be allowed access to in-person services if the beneficiary requests.
• Providers must ensure that beneficiary privacy and confidentiality is protected to the best of their ability.

Service Setting

Treatment must be provided in the setting most appropriate to the beneficiary’s individual treatment goals. Decisions regarding treatment setting(s) should be made on an individualized basis, in collaboration with the beneficiary’s family, and may include clinic-based, home-based, school-based or community settings, or any combination.

Transitions of Care

• Treatment plans should contemplate appropriate reduction in service intensity and generalization of skills across settings; and transition to natural and other paid supports (as needed, including any needed training). Additionally, if a provider is no longer able to provide services under NC Medicaid, they must, per provider contracts with NC Medicaid Managed Care, inform health plans and develop a transition plan for each impacted beneficiary.

Caregiver Involvement

Caregivers should be involved in assessment, treatment planning and treatment delivery (unless clinically contraindicated). Providers should contemplate caregiver participation needs to achieve the beneficiary’s goals and objectives.

State Monitoring and Investigations into Inappropriate Billing and Other Potential Indicators of Fraud, Waste or Abuse
NC Medicaid is continuing to monitor service delivery to ensure RB-BHT services meet all state coverage policy requirements as well as all applicable state and federal rules and guidelines. Monitoring efforts will include random onsite visits as well as desk reviews of medical records. NC Medicaid will investigate any suspected instances of inappropriate billing and other activities that may indicate fraud, waste or abuse. Such activities include but are not limited to:

• Inappropriate use of concurrent billing. 
• Billing practices that appear to be clinically unlikely or medically unnecessary. This could be indicated by caseload size, service utilization patterns or supervision hours that are inconsistent with expected clinical practice and provider operations.
• Excessive or exclusive use of telehealth to deliver services.
• Services delivered by providers that are not located near the beneficiary.
• Treatment planning that appears to be non-individualized or lack variability in treatment intensity across the provider’s practice.
• Lapsed provider credentials.
• A lack of discharges, service intensity titration and/or care transitions across the provider’s practice.

Thank you for your attention to this communication. All questions related to this Clinical Communication Bulletin can be sent to UM@TrilliumNC.org. Questions will be answered as quickly as possible

Rural Health Transformation Program Digital Health Survey for Providers and Practices

North Carolina is seeking to support health providers and practices for bold transformation to serve our nearly three million rural residents.

North Carolina is seeking to support health providers and practices for bold transformation to serve our nearly three million rural residents. NCDHHS and partners are working to modernize rural health through strengthened data connectivity, digital health infrastructure, advanced tools, and integrated support for providers across the state. As part of North Carolina’s Rural Health Transformation Program (NCRHTP) with funding from the Centers for Medicare & Medicaid Services (CMS), this digital health initiative aims to help rural practices overcome persistent barriers such as fragmented data systems, limited technological capacity, and resource constraints, while enabling adoption of innovative tools, from telehealth and interoperability improvements to AI supported workflows. 

Why now? Rural communities in North Carolina face persistent gaps in access, quality, and outcomes. Yet, the opportunity is clear: with robust partnerships, advanced data infrastructure, and a strong foundation of local health systems, North Carolina is poised to lead the nation in rural health innovation. The Rural Health Innovation Fund will help practices overcome barriers, like fragmented data connectivity, outdated technology, and resource constraints, by providing direct support for health IT upgrades, digital literacy, and adoption of cutting-edge tools such as AI-powered clinical decision support.

Your voice matters. NCDHHS is seeking input from rural health care providers to ensure that funding and technical assistance opportunities are responsive to the real needs of rural practices. By participating in this survey, you are helping shape a future where every rural North Carolinian can access high-quality, integrated, and resilient care, regardless of where they live. 

Who should participate? The survey is intended for providers and practices serving predominantly rural patient populations (defined as practices based in rural areas and/or in which more than 50% of patients live in rural areas). It takes approximately 5 minutes to complete. Take the survey 

Roadmap 2 Ready - September 2026

Each month we highlight a topic from the Centers for Medicare & Medicaid Services Emergency Preparedness Rule.

Know your risk for hurricanes and continue to monitor tropical activity through November 30, 2026. Additional recommendations before a hurricane include: 

1. Make an Emergency Plan
2. Know your Evacuation Zone 
3. Recognize Warnings and Alerts 
4. Review Important Documents 
5. Strengthen your Home
6. Get Tech Ready
7. Gather Supplies
8. Help your Neighborhood 

To find additional resources visit Ready.gov/hurricanes. If you have not already submitted your Disaster plans through the following link by May 1, 2026, Disaster Plan Submission, please do so as soon as possible. To confirm your disaster plan was received just check the "send me a copy of my responses" option at the end of the form.

Updated 1915(i) Assessment and Companion Guide Now Available

This bulletin applies to NC Medicaid Managed Care and NC Medicaid Direct.

The revised NC Medicaid 1915(i) assessment must be used starting Oct. 1, 2026, and includes a new companion guide.

The NC 1915(i) Assessment Tool, available on NC Medicaid’s website, identifies a beneficiary’s needed services and supports and informs the independent evaluation of 1915(i) eligibility determination and development of the Care Plan or Individual Support Plan. The updated assessment tool includes new fields that capture more detailed information. A new NC Medicaid 1915(i) Companion Guide has been created to accompany the updated 1915(i) assessment tool. 

Effective Oct. 1, 2026, the revised NC Medicaid 1915(i) Assessment Tool must be completed for: 

• Beneficiaries requesting a 1915(i) service; and 
• Eligibility reassessments for beneficiaries receiving 1915(i) services. 
  Previous versions of the NC Medicaid 1915(i) Assessment published prior to Aug. 3, 2026, will not be processed and will be returned marked as “Unable to Process.”

Updated Guidance on Birth Month Alignment for 1915(i) | NC Medicaid

Changes to Home Health Overlap Restriction

Trillium Health Resources has implemented a change to the Home Health services overlap restriction in HHAeXchange.
To avoid disruption in EVV billing for Home Health services, Trillium has removed the 7-minute overlap restriction from HHAeXchange. Please resubmit any previously rejected Home Health claims to HHAeXchange.

Network Providers: Monitoring NCTracks Communication

Encouraging network providers to regularly monitor all communications from NCTracks. NCTracks sends timely notifications regarding changes to the provider's profile, and providers staying informed will be essential to maintaining active network status.

Trillium Health Resources encourages network providers to regularly monitor all communications from NCTracks. NCTracks sends timely notifications regarding suspensions, terminations, and status updates related to NPIs, taxonomy codes, licensure, and other details related to provider profiles. Staying informed on these notices is essential to maintaining active network status. To avoid any disruptions in claims or services, network providers must regularly review all NCTracks notifications. 

Trillium Health Resources thanks the Provider network for maintaining proper oversight of NCTracks communication along with the quality services provided to members. If there are any questions regarding communication and notifications received from NCTracks. Please do not hesitate to contact NCTracks to address any concerns. NC Tracks can be contacted at 1-800-688-6696, and for your convenience.