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

Before April 30, 2026: Billing team must implement comprehensive compliance controls for all RB-BHT service claims: (1) Verify that all providers are enrolled as in-state providers (LQASPs and C-QPs) in NC Medicaid system and maintain current credentials and licenses. (2) Update billing system to reject or flag claims from out-of-state providers. (3) Implement validation checks to ensure: beneficiaries have final (non-provisional) ASD diagnosis from qualified provider within 6 months of provisional diagnosis; treatment plans are individualized and based on documented assessments using validated tools; treatment intensity is medically necessary and not excessive (flag cases with caseload patterns, supervision hours, or service utilization suggesting clinically unlikely patterns). (4) Stop billing for non-covered activities: recreational activities without tied therapeutic goals, nap/break time, transportation, childcare, custodial/respite care, academic teaching, duplicative IDEA services, staff-only meetings, or administrative tasks. (5) Ensure all LQASP/C-QP direct supervision of paraprofessionals is properly documented at clinically appropriate frequency and administrative supervision is NOT billed. (6) For telehealth claims: verify safety and effectiveness are clinically appropriate, not provider convenience, and beneficiary had choice of in-person services. (7) Document care transition plans and discharge rationale when providers leave NC Medicaid network. (8) Establish monitoring for fraud indicators: concurrent billing appropriateness, non-individualized treatment planning, exclusive telehealth use, out-of-area provider services, lack of service titration/discharges. Failure to comply will result in claim denials, provider investigations, and potential fraud/waste/abuse referrals.