Provider Communication 007

Reminder: Requirements for Research-Based Behavioral Health Treatment Service Delivery

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 TEACCHing

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. 

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/or 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/or 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 April 30, 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). See Clinical Coverage Policy (CCP) 8F, RH-BHT Services for more on LQASP and C-QP qualifications.

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

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 Clinical Coverage Policy 1H, Telehealth, Virtual Patient Communications, and Remote Patient Monitoring, 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 training needed). 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 on-site 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 lacks 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.

2026 Perception of Care Survey

Action Needed: 2026 Perceptions of Care Survey Participation

Each year, Trillium Health Resources and other Tailored Plans (TPs) across North Carolina support the NC Department of Health and Human Services (DHHS) in conducting the annual Perceptions of Care Survey. This mandatory survey gathers valuable feedback from individuals who have received mental health and/or substance use services, helping assess their experiences and satisfaction with care over the past year.

Administration Period: August 10 – September 18, 2026

Why This Matters

Survey results are submitted to the Substance Abuse and Mental Health Services Administration (SAMHSA), which publishes an annual report with results by TP. These results directly inform policy decisions aimed at improving behavioral health services statewide.

Your Role is Critical

If your agency provides mental health and/or substance use services, your support will be needed to assist with survey distribution. Trillium staff will provide full instructions prior to the start of survey administration.

Need assistance? Register to join our new Office Hours for survey guidance and Q&A. 

Key Details

• Survey Period:
  August 10 – September 18, 2026
• Format: Electronic/web-based and paper options
• Timely completion is essential.

2026 POC Office Hours (Optional)

Member Eligibility Criteria

Participants must:

• Have a mental health and/or substance use diagnosis
• Be a Trillium member with a valid Trillium member ID number
• Receive state-funded or Medicaid-funded service

Important Reminder:

Participation in this survey is a contractual requirement and cannot be billed as a service. Your engagement supports our shared goal of improving care for our members.

Next Steps for Providers

If your agency serves eligible members:

• Please email Surveys@TrilliumNC.org with the contact information for your designated survey coordinator
• For questions, contact Irmak Sherrod at Surveys@TrilliumNC.org or call 1-855-250-1539
• Trillium staff will be sending detailed instructions for survey administration—please monitor your email and be prepared to respond promptly

Thank you for your continued partnership. Your participation helps ensure the voices of our members are heard—and that we continue to grow and improve together.

Update from NCTracks- Special Virtual Office Hours Webinar for Taxonomy 251S00000X

The NC Medicaid Provider Operations and Behavioral Health Teams will host a Special Virtual Office Hours (VOH) webinar focused on updates for the organizational behavioral health taxonomy code 251S00000X (Community/Behavioral Health Agency). · 

• Date: Tuesday, August 18, 2026
• Time: 12:00 p.m. to 1:00 p.m.
• Agenda 
  • New requirements and Services added to the Provider Permission Matrix (PPM) and NCTracks system for Community Intervention Services (CIS) and Innovations Waiver Services (IWS) 
  • Changes to the categorical risk level for taxonomy 251S00000X
  • How to utilize the PPM to determine an appropriate Service and other criteria for a taxonomy
  • The NCTracks team will present a brief live demonstration of how to add and/or end-date a Service and taxonomy on the provider record in NCTracks 
  • Resources for 251S00000X enrolled providers 

This webinar is designed to ensure provider organizations are informed of current national accreditation and other taxonomy code 251S00000X requirements and have the necessary tools and resources to make updates to their provider record in NCTracks. All impacted providers are strongly encouraged to attend! 

Register for this Webinar

For assistance, contact: 

• NC Tracks Call Center: 800-688-6696 
• Provider Ombudsman: 866-304-7062

CCP 8F: Research-Based Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder (ASD)

Clinical coverage policy 8F: Research-Based Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder (ASD) is scheduled for implementation on September 26, 2026.

READ MORE
 

Roadmap 2 Ready - August 2026

Each month we highlight a topic from the Centers for Medicare & Medicaid Services Emergency Preparedness Rule. 
As you complete or update your Hazard Vulnerability Assessment, you may identify armed assailants or acts of violence as potential risks to address in your emergency planning. These situations present unique challenges, and while there is no single correct response method, prior planning is essential. Open discussion and scenario-based planning help staff make informed decisions should an incident occur.

To support your efforts, health care planners can use the Active Assailant Preparedness Checklist to:

• Mitigate risks on campus
• Strengthen response actions
• Improve recovery operations following an event

In any actual emergency, always follow your facility’s established armed assailant/active shooter protocols. Notify 911 immediately and use your internal communication systems to alert security and facility personnel.

This checklist was originally designed for hospitals but can be scaled to fit other health care environments.

If you still need to conduct your annual or biannual tabletop exercise, ASPR TRACIE offers several ready to use exercise packets that can help guide your organization through planning and discussion.

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.

Reminder – NC Medicaid Direct/ Medicaid TP Institutional Claims Coding Requirements for Therapeutic Leave

This notice serves as a reminder of the requirements for submitting institutional claims for Therapeutic Leave under NC Medicaid Direct/ Medicaid Tailored Plan.

Consistent with NC Medicaid Direct/ Medicaid TP institutional claims processing: HCPCS is required for Therapeutic Leave for Behavioral Health residential facilities.

Providers are reminded to review the complete requirements in the NC Medicaid Health Plan Billing Guide to ensure full compliance.