NC State Health Plan (PPO)

The Beacon Health Options North Carolina Engagement Center (NCEC) in Research Triangle Park has been part of the mental health and substance abuse services delivery system in North Carolina since 1992.

For all State Health Plan behavioral health telephone inquiries to Beacon Health Options, call 800-367-6143.

State Health Plan PPO

Beginning in October 2006, Beacon Health Options has responsibility to provide utilization review services for the State Health Plan PPO to determine if treatment is medically necessary. Beacon Health Options will authorize admission and concurrent stays for all mental health and substance abuse admissions for inpatient, substance abuse residential treatment centers, partial hospitalization, and intensive outpatient/structured outpatient treatment programs.

The fax numbers for the State PPO plan are as follows:
(877) 320-9938 for ITR submissions
(877) 320-0269 for ORF submissions

Applied Behavior Analysis

On January 1, 2015, the State Health Plan began providing coverage for Applied Behavior Analysis (ABA) treatment for members – diagnosed with Autism Spectrum Disorder (ASD) and meet certain other criteria. Information about coverage can be found in the benefits booklets posted on the State Health Plan web site at:  https://shp.nctreasurer.com/Pages/default.aspx  go to “Plans for Active Employees” and select the benefit package

Age and Diagnosis Requirements

Coverage for ABA treatment is only available to members who are younger than 26 years of age and have been diagnosed with Autism Spectrum Disorder.

Diagnostic Evaluation Requirements and Acceptable Diagnostic Tools

Coverage is only provided if the member is diagnosed with ASD by a licensed physician (MD or DO) or a licensed doctoral-level clinical psychologist (PhD or PsyD) based on a comprehensive face-to-face diagnostic evaluation using a clinically validated tool recognized by Beacon Health Options (the Mental Health Case Manager for the State Health Plan). A list of acceptable diagnostic and screening tools recognized by Beacon Health Options can be found at: http://www.cdc.gov/ncbddd/autism/screening.html.

The diagnostic evaluation does not require prior approval.

ABA Provider Requirements

When a member meets the age and diagnosis requirements listed above, the State Health Plan will provide coverage for, ABA treatment that is supplied either by (a) a properly licensed health care provider, or (b) a board-certified analyst who is supervised by a properly licensed health care provider. For purposes of coverage under the State Health Plan, the following types of health care providers may supply or supervise the supply of ABA treatment: psychiatrists licensed as a MD or DO; licensed doctoral-level clinical psychologists; developmental pediatricians licensed as a MD or DO; licensed clinical social workers; Licensed Clinical Social Worker Associates (LCSWAs) only when supervised by an LCSW; psychiatric mental health nurse practitioners and psychiatric mental health clinical nurse specialists; licensed psychological associates; licensed professional counselors; licensed professional counselor associate – LPCAs (must be supervised by LPC); certified fee-based practicing pastoral counselors; and licensed marriage and family therapists, licensed marriage and family therapy associates – LMTFAs (must be supervised by LMFT). When ABA treatment is supplied directly by one of these provider types, those services are covered only if the provider is currently licensed in the state in which the ABA services are supplied and the provision of ABA treatment is within the scope of practice covered by the provider’s license in that state.

The State Health Plan will only cover ABA treatment that is supplied by in-network providers (i.e., providers who are in-network with Blue Cross and Blue Shield of North Carolina or with the Blue Cross and Blue Shield Association through the BlueCard program and who meet the Plan’s provider requirements).

To find an in-network provider for ABA treatment in North Carolina, please speak with your child’s current mental health provider or your child’s Primary Care Physician, or call Beacon Health Options at 800-367-6143 or Blue Cross and Blue Shield of North Carolina at 888-234-2416 for assistance in finding an in-network ABA provider.

A list of in-network providers outside North Carolina can be found at: http://bcbs.prismisp.com/

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Citing NCGS §90-270.2, the State Health Plan has determined that Board Certified Behavior Analysts (BCBAs) and Board Certified Assistant Behavior Analysts (BCaBAs) are not properly licensed or otherwise authorized in North Carolina to provide ABA services without supervision. As a result, the State Health Plan only covers ABA treatment supplied by an unlicensed BCBA and BCaBA when that analyst is supervised by one of the properly-licensed health care provider types listed above. In such circumstances, the supervising provider must submit both the request for authorization (to Beacon Health Options) and the claim for payment (to BCBSNC). Even when an out-of-state BCBA or BCaBA is eligible to request authorization or submit claims for unsupervised ABA treatment in another state, the State Health Plan will not cover such services provided in that state unless the BCBA or BCaBA is supervised by one of the health care provider types listed above who is licensed in that state.

The State Health Plan will not cover ABA treatment that is supplied by substance use providers or counselors who are licensed or certified by the NC Substance Abuse Professional Practice Board (or a similar licensing body in the state in which ABA treatment is provided), but are not also licensed as one of the health care provider types listed above.

ABA Authorization Requirements

The State Health Plan requires authorization from Beacon Health Options prior to the start of any new ABA treatment or continuation of any ongoing treatment after the initial authorized period.

The first request for authorization submitted to Beacon Health Options by the treating or supervising provider should include:

  • the date of the diagnostic evaluation;
  • the results of the diagnostic evaluation;
  • the name and credentials of the diagnosing provider;
  • the name of the tool used in the evaluation, and
  • the clinical formulation of the diagnosis.

Authorization requests must be submitted to Beacon Health Options using an ABA review form (initial or concurrent). Those review forms can be found here.

The above link also includes ABA Provider Progress Report Guidelines.

All requests for authorization and any additional information that may be requested must be faxed to 877-320-0269 unless otherwise instructed.

ABA Medical Necessity Criteria

Authorization decisions for requests submitted by eligible providers are based on medical necessity criteria which can be found here.

ABA Authorization Codes

Beacon Health Options will authorize requests for AMA-approved ABA codes, which begin on page 6, Adaptive Behavior Assessments in the following document:

AMA-Approved ABA codes

These codes are explained in greater detail in the following document:

AMA Coding Guidance

Re-evaluation Requirements

  • Members who were not diagnosed by a properly-licensed health care provider who is a licensed physician (MD or DO) or a licensed doctoral-level clinical psychologist (PhD or PsyD) using an appropriate diagnostic tool, will need to be re-evaluated by a properly licensed health care provider prior to requesting authorization of ABA treatment services.
  • Members who were diagnosed by a properly-licensed health care provider who is a licensed physician (MD or DO) or a licensed doctoral-level clinical psychologist (PhD or PsyD) using an appropriate diagnostic tool and did not start ABA treatment within 6 months of diagnosis, will need to be re-evaluated to confirm or update their treatment plan prior to requesting authorization of ABA treatment services. (A re-diagnosis is not needed; however an updated ABA treatment plan is required). The rationale for this re-evaluation is the treatment plan should be confirmed and may need to be updated based on new information that has not been taken under consideration while the member was not receiving ABA treatment.
  • Members who were diagnosed by a properly-licensed health care provider who is a licensed physician (MD or DO) or a licensed doctoral-level clinical psychologist (PhD or PsyD) using an appropriate diagnostic tool and do not have an updated ABA treatment plan at the time of request for authorization, will need to be re-evaluated, to confirm or update their treatment plan.(A re-diagnosis is not needed; however an updated ABA treatment plan is required). The rationale for this re-evaluation is the treatment plan should be regularly monitored and updated as necessary, as there may be new information that has not been taken under consideration in the current treatment plan.)Note:  This re-eval may consist of a comprehensive history and justification/re-confirmation of the dx according to the current DSM-criteria for ASD; and/or the provider can use acceptable diagnostic tool(s).

Clinical Criteria Psychiatric

Clinical Criteria Substance Abuse

Authorization Request Forms

 

Online Services for BCBSNC Providers

(Online services available for contracted behavioral health providers serving members enrolled in the State PPO)

Medical Policies

The medical policies are located on the following link and are updated regularly.
https://shp.nctreasurer.com/Pages/default.aspx
Go to “Plans for Active Employees” and select the benefit package and search for “medical policies”

Prescription Drug Info

The PBM for the Plan is  CVS Caremark.

Provider Network Information

Blue Care Network
(out-of-state providers contracted with the national BCBS Association)

To find out of state/out of area providers (Blue Card): http://bcbs.prismisp.com 

Deficit Reduction Act

Fraud and Abuse

Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.

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