This bulletin clarifies and emphasizes key requirements under the Clinical Coverage Policy (CCP) 8F, Research-Based Behavioral Health Treatment (RH-BHT) Services. NC Medicaid recently posted a proposed revision of CCP 8F for public comment. The requirements discussed in this bulletin will not be impacted by upcoming revisions to CCP 8F.
Providers are advised of the following:
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 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.