2026 Q1 New BH Policies Webinar

As your partner in care, Buckeye is committed to supporting you in delivering high-quality behavioral health services to our members. These updated policies are designed to increase transparency, clarify expectations, and strengthen our collaboration so members receive the right care, at the right time, and at the right level.

We hope the webinar provided:

A clear overview of the new behavioral health policies and why they matter
Details on covered services and medical necessity criteria
Guidance on delivering care in alignment with the Ohio Administrative Code
Clarification of authorization and care coordination expectations
Information on where to go for ongoing support

We have provided the link to our survey and the the webinar slides below. Additional resources will be added when available.

Thank you again for attending or viewing our webinar.

If you were unable to attend our New BH Policies webinar on February 17 at 1:00, or you need a refresher, please click on the video to view.

Survey for February 17 Webinar

2026 New BH Policies Webinar Slides

Behavioral Health Policy 2-17 Webinar – Questions & Answers

Question: Can we bill H2020 and H0015 (IOP) on the same day? Thank you.

Answer: IOP group counseling is reimbursed as a per diem, unbundled group counseling service (H0015). When a member’s clinical needs support it, Therapeutic Behavioral Services (H2020) may also be provided on the same day, provided services are medically necessary, non‑overlapping, and supported by documentation. In addition, up to one hour of a separate, distinctly different group service may be provided when clinically appropriate.

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Question: Another question I have is surrounding rendering H0015 IOP and H2020 TBS Per Diem group on the same day. Is this allowed with prior authorization? Which service would require the prior authorization, or would it be both?

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Question: 27 units of IOP/year is a very specific number. Can you give studies, SAMHSA TIP information, or other data to support this?

Answer: Threshold was determined based on treatment duration of 9 weeks. SAMHSA Tip 47 suggests treatment for IOP may beup to 12 weeks (and beyond in some instances) with average treatment median of 81 days. The goal with reviewing at 9 weeks is to review progress with treatment plan and assess transition/ discharge plan to ensure next level of care services are identified.

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Question: When looking at H0015 limits (27 units per year), is this for any and all of these services, including different agencies? How will we know? Also, is it per year, like 12 months from start date? or per year, like calendar year?

Answer: Thresholds are per member across all providers. Claims information/ counts can be shared by contacting Buckeye's Provider Services line at 866-296-8731. Providers do not currently have real-time visibility into other agencies’ billing. Buckeye is exploring improved portal visibility to include all claims count information across providers.

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Question: You mentioned peer support should not be offered when a client is in a high level of care - such as ACT. is there any time that peer support could work with ACT teams?

Answer: Peer Support is generally not intended to duplicate higher levels of care such as ACT. Peer support is intended to be part of the ACT team model.

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Question: The Buckeye portal is problematic when it comes to submitting PHP authorizations. The code either isn't available or doesn't translate correctly so I have to use fax which is burdensome. If these new authorizations are going to be required more frequently, this needs to be addressed ASAP

Answer: Thank you for raising this—we’re aware of the PHP authorization issues in the Buckeye portal and agree this creates unnecessary burden. We’ve flagged this with our configuration and IT teams so it can be corrected, especially given the increased use of authorizations; fax submissions will continue to be accepted while this is addressed.

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Question: If SAMHSA TIP indicates that the best practice for IOP is 90 days, how was it determined to limiti IOP to 27 units/year?

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Question: As the services are showing calendar year benefits, such as H2020 25 units or H0015 17 units, how are providers supposed to verify how many a client has used? We would need to know this information to be able to know when a prior authorization request is going to be needed?

Answer: Claims information/ counts can be shared by contacting Buckeye's Provider Services line at 866-296-8731. Providers do not currently have real-time visibility into other agencies’ billing. Buckeye is exploring improved portal visibility to include all claims count information across providers.

Question: For residential stays. there is a process to see how many stays a client had per year. Will there be a similar system to check client's utilization for IOP before the provider renders the service?

Answer: At this time, no—there is not a provider‑facing system like residential stay tracking that allows you to check a member’s IOP utilization before services are rendered. Buckeye can see utilization internally, but providers do not currently have real‑time visibility into a member’s IOP units across agencies. Buckeye will consider development and implementation of a form similar to the residential treatment process.

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Question: Can you have a peer support services while on IOP?

Answer: Yes, peer support is allowed while a member is in IOP, but it cannot be billed separately if it happens during IOP program hours

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Question: What evidence based level of care are you using?

Answer: Thresholds are informed by ODM guidance, national best practices, utilization data, and clinical standards.

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Question: Hello, my question is we, Volunteers of America Ohio and Indiana, we are a SUD type 95, does that policy for IOP regulatory basis OAC 5160-27-009 ASAM Level 2 the same for ASAM 3.5?

Answer: No—the IOP regulatory basis in OAC 5160‑27‑09 and ASAM Level 2 does not apply to ASAM Level 3.5.ASAM 3.5 (residential treatment) is governed under different Ohio Administrative Code rules and has its own medical‑necessity and authorization requirements.

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Question: May we have clarification on the PA requests being submitted at least 5 days prior to starting service, specifically with IOP, many clients are assessed and begin same or next day, also the tx plan is not done 5v days prior to the client starting treatment.

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Question: Will IOP PA need requested before they start day 1 in that level of care or 5 days prior to the day they will require the PA?

Answer: IOP prior authorization is not required before day 1. Providers should request PA about 5 business days before the member is expected to exceed the IOP threshold (after 27 per‑diem units)—not at admission. Services may start and continue up to the threshold without PA; the request is only needed in advance of continued IOP beyond that point.

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Question: Your slide on "No Prior Auth. Requirement" for "standard delivery" includes CPST, PSR, TBS, Peer Support. It leaves out IOP/PHP. Please clarify. Thanks.

Answer: Good catch. The slide was intentional—“no prior auth for standard delivery” applies to CPST, PSR, TBS, and Peer Support only. IOP/PHP are handled separately because they are per‑diem levels of care and follow their own authorization rules, which is why they were not included on that slide.

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Question: What does the 27 units per year mean in regards to IOP services?

Answer: The 27 units per year for IOP means up to 27 per‑diem days of IOP (code H0015) per member per calendar year can be billed without prior authorization. Once a member reaches the 27th IOP day, prior authorization is required for any additional IOP days, and services may continue if medical necessity is approved.

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Question: SO, THERE WILL ONLY BE 27 IOP SESSIONS ALLOWED WITHOUT PA EVERY YEAR, THEN PA IS REQUIRED.

Answer: Yes—that’s correct. Each member may receive up to 27 IOP per‑diem days (H0015) per calendar year without prior authorization, and PA is required for any IOP days beyond the 27th based on medical necessity.

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Question: Currently we have a couple of residential facilities, sometimes H2036 or H2034 is denied for PA, at which point, our clinical staff may still feel the client needs additional services, so we will see those clients under IOP level services with an overnight at the residential facility.......what if the IOP is denied under this new process? I am highly concerned about what the safety net is for those clients.

Answer: We share your concern about safety, and there is a safety net. A denial of residential (H2036/H2034) or IOP does not mean care must stop—providers can request peer‑to‑peer review, submit additional clinical information, or request an expedited review when there are safety or risk concerns, and alternative clinically appropriate levels of care can be authorized based on medical necessity.

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Question: when specifying the limits for multiple services, for H2019 and H0015, if H2019 is the per diem, does that count as 1 unit? Or is the per diem 8 units?

Answer: H2019 is not a per‑diem code. H2019 is billed in 15‑minute units, so it counts by the actual number of units billed (up to 8 units per day)—it does not convert to a single “per‑diem” unit. When H0015 (IOP per diem) is billed on the same day, H2019 units are limited to a combined total of 4 units with other rehabilitative services; the IOP per diem itself does not count as units toward that limit.

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Question: Do we have to do a prior auth for IOP and PRS services now?

Answer: No—prior authorization is not required to start IOP or PRS; PA is only needed if IOP exceeds 27 per‑diem units in a calendar year or if PRS exceeds 24 units per week or extends beyond 26 weeks.

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Question: Can IOP and TBS services be requested on the same fax form?

Answer: Yes. IOP (H0015) and TBS (H2019/H2020) can be requested on the same fax form as long as each service is clearly identified with its own code, requested units/days, date range, and clinical rationale. Just note that they cannot be authorized or rendered on the same date if both are per‑diem services, so the request should reflect separate, non‑overlapping dates where applicable.

Question: If Agency A and Agency B both provide 16 units of TBS on the same day to the same member, who would get paid first? Is it based on claim submission date? How can both agencies get paid in this scenario?

Answer: When multiple providers deliver services to the same member on the same day, reimbursement is based on daily unit limits that apply across all providers. Claims are adjudicated in the order received. To avoid denials, providers should coordinate care, ensure services are non‑duplicative, and remain within applicable daily limits.

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Question: Is the H2020 limit of 25 untis for TBG group per diem? 25 units of the individual service would only be 6.25 hours

Answer: H2020 is a per diem code. PA is required after 25 per diem units.

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Question: Do these thresholds replace BH Redesign/Audits/Edits/Limits document? "The combination of SUD case management, CPST, TBS, PSR, SUD assessment, SUD counseling cannot exceed 96 units (24 hours) on same date of service"

Answer: Yes—the new UM thresholds replace the prior BH Redesign/Audits/Edits/Limits rule, including the blanket 96‑unit (24‑hour) same‑day cap. The older edit is no longer used; instead, Buckeye now applies service‑specific thresholds and same‑day limits with review triggered only when those thresholds are exceeded, consistent with ODM‑approved (pending) policy and current guidance.

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Question: I hear you saying that the policy does not require PA for standard delivery of PSR, TBS, CPST but standard delivery for our population is extensive. We serve those with SPMI and our standard delivery is significant. How did Buckeye choose these threshholds?

Answer: Thresholds are informed by ODM guidance, national UM standards and best practices, utilization data, and clinical standards. Buckeye reviewed other states to consider UM thresholds and limits.

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Question: Can you share the research behind the yearly limits that were set for TBS and PSR services?

Answer: Thresholds are informed by ODM guidance, national best practices, utilization data, and clinical standards. When reviewing other state Medicaid MCO guidelines, the following MCO thresholds were considered:
Florida: H2017/ H2019- PA required for all services unless billed in a group setting.
Kentucky: H2017- PA required after 500 units
Louisiana: H2017- PA required for all services

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Question: What about if client comes mid year and dont know how many units were used, should we assume a prercert is needed like for h2020

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Question: H2019 is billed as a 15-minute unit, which means the annual benefit of 80 units per
year is 20 hours per year. How was it determined this was sufficient hours to
support individuals with SMI and SED as a chronic condition management model of
care?

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Question: does TBS have to be interactive- can one way emails or texts regarding art thereapy groups be billed for example- can you define what substantiates TBS with clients?

Answer: Regulatory basis: OAC 5160-27-08 Services use goal‑directed, solution‑focused interventions, including treatment planning, crisis prevention, and support to improve social skills or daily functioning. All activities are tied to documented treatment goals.

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Question: Will H2020 per diem and TBS H2019 be allowed to bill on the same day by same agency? PA required?

Answer: Yes—H2020 (TBS per diem) and H2019 may be billed on the same day by the same agency. When H2020 is billed, other rehabilitative services (including H2019) are limited to 4 total units that day. PA is not required for same‑day billing unless unit thresholds are exceeded or an additional per diem is billed by a different agency.

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Question: How was it determined this 20 hour per year limit for TBS H2019 was sufficient hours to
support individuals with SMI and SED as a chronic condition management model of
care? What is the projected response time for PA requests over the daily/annual limits? Is your PA process operating correctly? Faxing PAs is administratively burdensome and unreliable. How do providers receive PA DURING a service, for daily limits?

Answer: The 80‑unit (20‑hour) H2019 threshold is a review trigger based on historical use and Ohio Medicaid standards—not a cap, and additional TBS is available when medical necessity is documented. Standard request is calendar days; expedited is 48 clock hours; concurrent is 3 calendar days. We will continue to work with providers on best practices.

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Question: Please distinguish between TBS and CPST with examples

Answer: CPST focuses on building daily living and coping skills to help members manage symptoms and function in the community (for example, learning routines, medication support, and problem‑solving). TBS is more intensive and behavior‑specific, targeting reduction of unsafe or disruptive behaviors through structured interventions (for example, one‑on‑one work to reduce aggression or severe outbursts).

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Question: Will Place of Service have different limits? For instance: CPST done at home and in the office and TBS Day Treatment done in office. Are the limits still the same?

Answer: Thresholds are based on the service provided and not the place of service.

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Question: H2020 has limitations for those over the age of 21 called out in the OAC. Is Buckeye following that or will the additional 4 units per day be applied to those under the age?

Answer: Buckeye is following the Ohio Administrative Code age limitations for H2020. The additional same‑day units apply only when H2020 is otherwise a covered service, so in practice that means they apply to members under age 21, consistent with OAC requirements.

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Question: Since nursing bills H2017 and H2019, will those not be included as they are not part of the procedures listed?

Answer: UM thresholds apply to the procedure code, not the staff type. When nursing bills H2017 (PSR) or H2019 (TBS), those units count toward the same daily, annual, and combined‑unit thresholds as when the codes are billed by other qualified behavioral health staff.

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Question: For TBS will a prior authorization before 80 units MUST be completed?

Answer: No. A prior authorization is not required before 80 units for TBS billed under H2019. Providers may deliver up to 8 units per day and 80 units per calendar year without PA; PA is only required once the 80‑unit threshold is exceeded, based on medical necessity

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Question: How are we supposed to request a prior auth for something like TBS beforehand if we don't know that it is going to go over the daily threshold?

Question: Is the billing criteria the same for FQHC facilities?

Answer: FQHCs bill under a per‑visit (PPS) model, not unit‑based billing. Behavioral health services delivered by an FQHC are billed as an FQHC encounter (T1015 with modifier U3) when the service qualifies as an FQHC service.

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Question: What data/research/best practices are these policies based on?

Answer: Thresholds are informed by ODM guidance, national UM standards and best practices, utilization data, and clinical standards.

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Question: What data/research/best practices are these policies based on?

Answer: Thresholds are informed by ODM guidance, national UM standards and best practices, utilization data, and clinical standards.

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Question: How are providers expected to know what other organizations are billing on the same day?

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Question: Hello. I am from Nationwide Children's Hospital and we bill behavioral health services as a hospital (provider type 01). We bill on a UB-04 claim form and our claims are processed under EAPGs. My understanding is that our claims follow ODM EAPG covered code guidelines for coverage and auth requirements. Because of that, these coverage and auth policies would not apply to our claims. Is that correct? Thank you

Answer: EAPG codes would be exempt from these policies.

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Question: Will you be sending the slide show too?

Answer: Slides will be posted to Buckeye's website.

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Question: how are we supposed to know if other agencies providing servicces also?

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Question: Does this apply to both adults and children?

Answer: Yes. The thresholds apply to both adults and children. They are tied to the service and billing code, not age, and apply across the Buckeye Medicaid behavioral health benefit.

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Question: when will we be provided the slides from today?

Answer: Slides will be available through Buckeye's BH website.

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Question: Will you work with other MCO's to have similar rules among others?

Answer: Yes—Buckeye is committed to working with ODM and other MCOs to align rules as much as possible. The goal is consistency across plans while still meeting state requirements and allowing flexibility for member needs.

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Question: How do we know if other provider organizations are involved? If the client doesn’t provide us the information, we have no way to know.

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Question: Are the changes for network providers?

Answer: Yes. These changes apply to Buckeye’s network providers. The UM thresholds and review processes are applied consistently across in‑network behavioral health providers, based on the service and billing code—not provider type, and were reviewed and approved by ODM as part of Buckeye’s behavioral health policy updates. All out of network providers require prior authorization for all services.

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Question: Buckeye is putting more administrative on providers. We already have extensive admin burden to dispute Buckeye inappropriate denials. What is Buckeye doing to offset this?

Answer: We hear that concern and recognize the added administrative burden. To help offset this, Buckeye is limiting PA to defined thresholds (not service start), allowing services to continue during review, offering peer‑to‑peer discussions before adverse decisions, and working to improve guidance, FAQs, and system functionality to reduce avoidable denials and rework.

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Question: will you allow retro auths?

Answer: Retro authorizations are reviewed on a case-by-case basis.

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Question: shouldn't ODM and Buckeye Medical necessity be one and the same?

Answer: Yes, they are the same.

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Question: If you have mulitple clinics do you get different provider enagement member assigned?

Answer: For more information, you can outreach Provider Services Support:
Medicaid
Monday - Friday 7 a.m. to 8 p.m
866-296-8731

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Question: What version of the ASAM critieria is acceptable? When is Buckeye switching to ASAM 4th Edition?

Answer: Buckeye currently accepts ASAM 3rd Edition for utilization management and medical‑necessity reviews, consistent with Ohio Medicaid guidance. Providers may also reference ASAM 4th Edition where clinically appropriate, but the 3rd Edition remains the required standard until the state completes the formal transition

Question: When does this go live?

Answer: There is no finalized implementation date at this time. Buckeye will provide advance notice and will not apply policies retroactively.

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Question: When is this going into affect

Answer: There is no finalized implementation date at this time. Buckeye will provide advance notice and will not apply policies retroactively.

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Question: no known or published effective date yet

Answer: There is no finalized implementation date at this time. Buckeye will provide advance notice and will not apply policies retroactively.

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Question: I know you mentioned the timeline for implementation is not firm, but do you have an estimate?

Answer: There is no finalized implementation date at this time. Buckeye will provide advance notice and will not apply policies retroactively.

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Question: Are there plans to remedy the increased Administrative burden on agencies?

Answer: Yes—Buckeye recognizes the increased administrative burden and is actively working to reduce it where possible. This includes limiting PA to defined thresholds (not service start), improving guidance and FAQs, and addressing system and portal issues to streamline submissions as these policies roll out.

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Question: I have one more question. Regarding the standard requests that must be submitted 5 business days prior to the service- what is the turn around time for your decision? Current responses are 2 days for expedited and 7 for standard. If we submit 5 days ahead of time to the service, will we have the determination in time for that scheduled service?

Answer: Standand authorizations will be reviewed and notification will occur within 7 days, urgent requests are determined within 48 hours.

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Question: Steps for resolution - how quickly will we be give the approval or denial?

Answer: Standand authorizations will be reviewed and notification will occur within 7 days, urgent requests are determined within 48 hours.

Question: Can you review the H0038 again? I got 24 units/week but didn't understand 26 weeks/year

Answer: H0038 does not require PA until 24 units/ week and/ or 26 calendar weeks are exceeded.

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Question: How was the limit of 24 units (6 hours) per member per week, not to extend beyond 26 weeks per member per calendar year for peer services determined? What data or research supports such limitations?

Answer: Thresholds are informed by ODM guidance, national UM standards with other peer support services , utilization data, and clinical standards. These are not hard limits or caps on services, and approvals beyond these thresholds will be based on medical necessity. Other state MCO limits were reviewed for comparability.

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Question: For Peer Support is a PA needed for anthing over 24 hours in one week or over 26 weeks a year or does this trigger a review?

Answer: Up to 24 units (6 hours) per week and/ or up to 26 weeks per calendar year. Exceeding these thresholds triggers review and requires PA with supporting documentation to demonstrate medical necessity.

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Question: How was the limit of 24 units (6 hours) per member per week and not to extend
beyond 26 weeks per member per calendar year for peer services determined? What
data or research supports such limitations?

Answer: Thresholds are informed by ODM guidance, national UM standards and best practices, utilization data, and clinical standards. SAMHSA’s TIP 64: Incorporating Peer Support Into Substance Use Disorder Treatment Services describes peer support as a recovery-oriented, non-clinical component integrated across continuum of care (pre-treatment, treatment, recovery). It does not set specific hour or session requirements, because peer support is tailored to individual recovery needs and treatment plans.
The focus is on matching peer support to clinical goals, enhancing engagement, retention, and linkage—not on standardized dose/duration.

Other Medicaid states have implemented various prior authorization thresholds for peer support services including the following:
Virginia: 16 units/ day, 900 hours per year
Kentucky: 8 units/ day, 800 units per year (200 hours)
Texas: 104 units (26 hours) / 6 months
North Carolina: 24 units (6 hours) / year
Buckeye's thresholds are more expansive than the states included in this review.

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Question: Peer Support is a part of the ACT teams however, you stated that the service is not provided with ACT, can you explain please?

Answer: Peer Support is part of the ACT team model, but it is not billed as a separate Peer Support service while a member is enrolled in ACT. Under Ohio Medicaid rules, ACT is a bundled, team‑based service, and the peer role is already included in the ACT per‑diem rate, so Peer Support (H0038) cannot be billed separately at the same time.

Question: Buckeye struggles to pay BH claims appropriately as it is, what are you doing to guarantee that prior auths (UM reviews) are going to be processed in a timely manner and paid appropriately?

Answer: Prior authorization is not required for standard delivery up to published thresholds. PA is required only when services exceed daily, weekly, or annual thresholds. ODM-required timelines apply, which is 48 hours for urgent requests and 7 days for standard requests.

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Question: Are these the FINAL thresholds? ODM had advised that they told all MCO's to collaborate and submit for final review/approval. Does Buckeye anticpate these thresholds changing?

Answer: No, the policies are not final and we are awaiting approval from ODM.

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Question: Are these soft limits per patient or per organization? If it is per patient, how will an organization determine how many services a patient has already had?

Answer: Thresholds are per member per calendar year across all providers. Providers do not currently have real-time visibility into other agencies’ billing. Buckeye is exploring improved portal visibility.

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Question: If a threshold is hit services must be paused until the review or PA is completed?

Answer: No—services do not need to be paused when a threshold is reached. Thresholds trigger a review or PA process, but services may continue while the review is underway, with decisions based on medical necessity rather than requiring care to stop. Prior authorization service requests may also be submitted retrospectively.

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Question: Are these PA limits per patient or per organization?

Answer: These thresholds are per member per calendar year across all providers.

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Question: You want a PA 5 days in advanced? THat is not realistic because our client are SPMI and constantly in crisis...we do not know in advance of when we are going to provide services or when we are going to meet the threshold?

Answer: Members in need of crisis care would not require PA. Any service with a KX modifier would not be subject to PA thresholds.

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Question: Will this do away with half rates all together and does this impact Day Treatment?

Answer: No- those will still apply.

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Question: Which services require prior authorization?

Answer: Prior authorization is not required for standard delivery up to published thresholds. PA is required only when services exceed daily, weekly, or annual thresholds. PA UM Thresholds are as follows: H2020- after 25 sessions, H2019- after 8 daily units/ 80 total units, H2017- after 8 daily units/ 120 total units, H0015: after 27 sessions.

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Question: Would these UM limits apply to the client regardless of agency? If so, how will we know if the patient has had services at another agency?

Answer: Thresholds are per member across all providers. Providers do not currently have real-time visibility into other agencies’ billing. Buckeye is exploring improved portal visibility to include claims counters. Claims information/ counts can also be shared by contacting Buckeye's Provider Services line at 866-296-8731.

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Question: Is your PA process operating correctly? Currently providers must fax PAs which is administratively burdensome and unreliable.

Answer: Yes, Buckeye's portal is operating correctly. If you experience difficulty, you can outreach Provider Services Support:
Medicaid
Monday - Friday 7 a.m. to 8 p.m
866-296-8731

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Question: The policy for multiple services on the same day indicates the combination of
services provided by any organization will be included in the policy, how will
organizations determine the number of units billed by other organizations in real
time each day? This is not feasible even if the portal works/is updated.

Answer: Buckeye is working to improve portal functionality. Determinations will be available via the portal and mailed when required. Claims information/ counts can also be shared by contacting Buckeye's Provider Services line at 866-296-8731.

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Question: Is any additional payment available to support implementation of the new administrative requirements?

Answer: At this time, there is no additional payment or administrative add‑on tied specifically to implementing these new UM requirements. The focus has been on limiting PA to defined thresholds and improving guidance and system processes to reduce burden rather than adding new payments.

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Question: Is there a maximum amount of hours that will be authorized at one time?

Answer: No- each request is reviewed individually and determinations are based on the individualized care plans, including the problems, goals, objectives and interventions. This information helps determine the additional units that are authorized per request.

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Question: so a client cannot receive PRS for any longer than 1 year without the review?

Answer: These policies establish utilization review thresholds. Services may continue beyond thresholds when medical necessity is documented and approved. The PA threshold for peer support is 24 units/ week and/ or 26 calendar weeks. Services will be reviewed and approved based on medical necessity.

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Question: How are providers supposed to know if a client is seeking services elsewhere, in order to follow the unit max per client? We can't see what other companies bill.

Answer: Thresholds are per member across all providers. Providers do not currently have real-time visibility into other agencies’ billing. Claims information/ counts can be shared by contacting Buckeye's Provider Services line at 866-296-8731.

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Question: So, no PA required once pending policy goes into effect

Answer: PA will be required at thresholds for each of the services reviewed after the policies go into effect.

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Question: How long will it take to get a response to prior authorizations?

Answer: Standand authorizations will be reviewed and notification will occur within 7 days, urgent requests are determined within 48 hours.

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Question: Is the prior authorization form available now on the website? I am not able to find it.

Answer: The new PA form will be posted once approved and finalized by Medicaid.

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Question: If services were rendered by another agency previously in the year, how can you verify if units have been met and a PA is needed?

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Question: Your presenter said that the new thresholds/policies were put on pause in order to provide this information. My understanding is that Medicaid put a pause on these policies. Can you provide the information of where/when/how you spoke to providers or received other feedback?

Answer: ODM required the pause while completing the ARPA reconiliation process. ODM also required the plans to complete stakehohlder feedback sessions and incorporate that feedback into our strategy. Engagement with providers occurred through provider alerts, webinars, listening sessions, surveys, written feedback, and direct provider communication.

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Question: Are your PA forms unique or do you corredinate with other Onio MCOs?

Answer: Buckeye developed a PA form for the new BH services and it is currently pending approval with Ohio Medicaid.

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Question: Since this is per patient/member, how will an organization determine how many services a patient has already had in a calendar year or day? There was mention of a care coordination portal to determine this
information, but providers do not have access to this information in the portal.

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Question: If these limits were reached from another agency, how is a new agency going to know if they have to get a prior authorization?

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Question: So, will claims automatically be denied if they aren’t ‘caps on care’, if we don’t submit prior authorization? That is the definition of ‘cap of care’

Answer: Claims will deny if an authorization is not received when services reach the UM thresholds. The thresholds are not hard caps, and services will be approved beyond the thresholds based on medical necessity. Buckeye does not have any hard limits for any BH service.

Question: Will reviews and documentation submissions be required be pre/post payment?

Answer: Reviews are utilization review thresholds, not pre- or post-payment audits. Documentation is requested only when thresholds are exceeded.

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Question: What is the expected time frame for return on UM reviews on Buckeye's end?

Answer: Standard requests is 7 calendar days; Expedited is 48 clock hours; Concurrent is 3 calendar days

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Question: Providing all clinical documentation is provided and medical necessity is proven, what is the turnaround time for prior authorization responses by Buckeye?

Answer: Standard requests is 7 calendar days; Expedited is 48 clock hours; Concurrent is 3 calendar days

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Question: Is your portal able to accept all PA requests? I've heard from several of our members that they can only fax PAs

Answer: We covered the ways that PA requests can be filed during the webinar. Please outreach Provider Services Support:
Medicaid
Monday - Friday 7 a.m. to 8 p.m_x000B_866-296-8731.

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Question: how fast will buckeye review documentation requests?

Answer: Standard requests is 7 calendar days; Expedited is 48 clock hours; Concurrent is 3 calendar days

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Question: Will there be an easy way to see how many units of services that the member has used so we know if we need to prior auth the service or not?

Answer: Thresholds are per member across all providers. Providers do not currently have real-time visibility into other agencies’ billing. Buckeye is exploring improved portal visibility.

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Question: Will you be providing sessions on how to submit Prior Auths on your portal? these details are very important.

Answer: Yes, you can outreach Provider Services Support:
Medicaid
Monday - Friday 7 a.m. to 8 p.m_x000B_866-296-8731

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Question: What is the projected response time for PA requests over the daily/annual limits?

Answer: Standard requests is 7 calendar days; Expedited is 48 clock hours; Concurrent is 3 calendar days

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Question: How do you submit a PA for certain services 5 days in advance when someone needs help today? In the world of behavioral health, there are rarely times where you have a 5 day heads up for services.

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Question: is a pa required only if it is over the threshold of units?

Answer: Yes, that is correct.

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Question: Will these be reviewed by a human or AI?

Answer: We have a utilization management team who will be doing all reviews.

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Question: This is drastically going to impact the care we provide to clients. What is Buckeye doing to explain to their members that we may not be able to offer them as many services because you are putting UM review in place and creating additional work for the provider?

Answer: Buckeye is not reducing covered benefits or limiting access to care. The utilization management (UM) thresholds were put in place to align with Ohio Medicaid rules and to ensure services remain medically necessary and person‑centered, not to deny care.

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Question: What will be the approved increment of units and date range for each Prior Auth?

Answer: This would be determined on a case by case basis. Be sure to include all appropriate documentation for best review opportunity.

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Question: So again what services have to have a PA?

Answer: Most behavioral health services do not require prior authorization unless a utilization threshold is exceeded; PA is triggered for IOP (after 27 per‑diem units/year), TBS (after 25 H2020 units/year or over 8 H2019 units/day or 80/year), PSR (over 8 units/day or 120/year), Peer Support (over 24 units/week or beyond 26 weeks/year), and outpatient psychotherapy (after 24 units).

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Question: so, no PA required oncepenf

Answer: nan

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Question: What is turn-around time for PA approval or denial?

Answer: Standand authorizations will be reviewed and notification will occur within 7 days.

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Question: Hi, when does this authorization process go into effect? Thanks.

Answer: There is no finalized implementation date at this time. Buckeye will provide advance notice and will not apply policies retroactively.

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Question: will auths be issued for specific visits or can we get approval to give more units to a particular member based on their needs. Such as saying someone can have 400 units per year instead of the limit of 80 units per year.

Answer: When a member’s needs exceed a threshold, Buckeye can approve additional units based on medical necessity. The approval is typically for a defined number of units over a period of time (not an open‑ended annual total), and providers can request higher unit amounts when documentation supports the member’s clinical needs—meaning approval can go beyond standard thresholds when appropriate.

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Question: Two questions- will a claim automatically be denied if we bill more than the cap without a prior auth? And what is considered a clincially qualified staff person?

Answer: A claim billed above the established threshold without an approved prior authorization is subject to denial, which is why Buckeye encourages submitting the PA as soon as the need is identified so medically necessary services can continue without interruption. A clinically qualified staff person is someone who meets Ohio Medicaid and Ohio Administrative Code requirements for the specific service being delivered (such as licensed, certified, or credentialed staff, including certified peer support specialists when applicable) and is working within their approved scope of practice.

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Question: If a prior authorization needs to be submitted five business days in advance of a member receiving services that would put them above the limit, how does this process ensure quality client care? What should providers do while waiting for the prior authorization to be approved?

Answer: While PA is pending, providers should continue services within the allowed threshold and submit the PA as soon as the need is identified with clear clinical documentation. If there is clinical urgency or risk to the member, request an expedited review and coordinate with the member and care team to maintain safety and continuity.

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Question: We need to submit at least 5 days in advance for a prior authorization. How quickly will we be informed that the request is approved or denied?

Answer: Standand authorizations will be reviewed and notification will occur within 7 days, urgent requests are determined within 48 hours.

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Question: Also, when will this go into affect? We have been told Ohio Medicaid has not approved these changes as of yet, so please provide a date as all of our Buckeye clients will need prior authorization given their utilization of services

Answer: There is no finalized implementation date at this time. Buckeye will provide advance notice and will not apply policies retroactively.

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Question: When will we need to begin submitting prior authorizations?

Answer: There is no finalized implementation date at this time. Buckeye will provide advance notice and will not apply policies retroactively.

Question: What is the projected response time for PA requests over the daily/annual limits?

Answer: Standand authorizations will be reviewed and notification will occur within 7 days, urgent requests are determined within 48 hours.

Question: Also, if the units follow the client and not the individual agencies, how can we check utilization? When speaking with ODM, they indicated that Buckeye had told them that the agencies have access to utilization management on their portal. I am the registered Admin for the Buckeye portal as well as the Availity portal for our agency and have been unable to locate anything that indicates utilization management for these services for our clients.

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Question: Will denial/approval notices be available on the portal instead of or in addition to being mailed?

Answer: Buckeye is working to enhance portal functionality. Determinations will be available via the portal and mailed when required.

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Question: Will we be able to track thresholds on clients on buckeye? so we can see if new clients coming in have met thresholds at another agency?

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Question: How are providers suppose to track other services at other agencies for these thresholds?

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Question: You stated it's not a cap on services. How is it not considered a cap, when you are limiting Per Day services to 8 units, which is 2 hours? A clinician in the field isn't going to be able to stop seeing that client at the 2 hour limit and log into a portal (Which they currently can't even access) to request Pre-auth to continue seeing the client for whatever needs they are having at the moment.

Answer: We understand the concern, and the daily unit threshold is not intended to stop care mid‑visit or require real‑time portal access in the field. It is a prospective review trigger, meaning providers should anticipate ongoing needs and request authorization in advance, with flexibility for urgent situations, so medically necessary services can continue without interruption rather than functioning as a hard cap. If services extend beyond a daily limit, a retrospective request may be submitted for review and approval.

Question: How will agencies know when their member is approaching service limits when these service limits are shared across multiple agencies and organizations?

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Question: Will Buckeye being publishing client specific usage, similar to AWV and other quality based codes so provider can ensure they are not exceeding limits without consulting the clients.

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Question: The webinar did not mention how we are able to monitor how many current units they have YTD.

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Question: Will the units be reimbursed up to the limitation if the total exceeds the limit?

Answer: Yes. When a claim exceeds a daily or annual limit, Buckeye will reimburse the units up to the allowed limit and deny only the excess units, rather than denying the entire claim. This is treated as a coding denial for the over‑limit units, with payment made for the allowable portion.

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Question: Is there a period of time the additonal units will be authorized, such as 24 units to be used through March 31.

Answer: Yes—when additional units require PA, they are authorized for a specific date range tied to medical necessity, not as an open‑ended or automatic period (like “through March 31”). The approved units must be used within the authorized dates, and continued services beyond that timeframe would require a new review and approval based on updated clinical information.

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Question: when it is known all of these policies and units counts/threshholds they start with that date and go forward ? or will there be any look back to service provided so far this calendar year?

Answer: Annual thresholds are based on the calendar year unless otherwise specified in policy.

Question: How can you submit 5 days prior for PSR for medical necessity?

Answer: If you would like to, you can outreach Provider Services Support:
Medicaid
Monday - Friday 7 a.m. to 8 p.m
866-296-8731

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Question: When a long CPST encounter is needed in order to support the client with medical needs, would that always require preauth?

Answer: No—longer CPST encounters do not automatically require prior authorization. PA is only needed if CPST exceeds the established daily or annual thresholds; otherwise, longer visits can be billed when medically necessary and well documented.

2026 Q1 New BH Policies Webinar

Intensive Outpatient (IOP) / Levels of Care

Therapeutic Behavioral Services (TBS)

General Policy & Implementation Questions

Peer Support Services

Prior Authorization & Utilization Review

Portal, Tracking & Visibility Issues

Thresholds, Units & Limits

CPST / PSR