Behavioral Health Prior Authorization Information

Table A-1: New Services Subject to Utilization Management

This appendix defines the utilization management thresholds and authorization turnaround times for select behavioral health and substance use disorder services. These requirements apply across all provider guidance documents and are separate from daily unit limits or same-day billing rules.

Important Notes

• Prior authorization thresholds apply on a calendar-year basis unless otherwise specified.
• Combined thresholds apply across services where indicated.
• Daily unit limits, same-day billing rules, and non-duplication requirements continue to apply and are addressed elsewhere in provider guidance.
• Authorization decisions are based on medical necessity and compliance with Ohio Medicaid requirements.
  

1) What are Therapeutic Behavioral Services (TBS)?
Therapeutic Behavioral Services (TBS) are individualized, goal‑directed behavioral health interventions designed to reduce and manage behavioral or emotional symptoms and improve functioning in the community. TBS interventions must be tied to clearly defined goals and objectives in the individualized treatment plan (ITP) and delivered in accordance with Ohio Medicaid requirements (OAC 5160‑27‑08).

2) What is Psychosocial Rehabilitation (PSR)?
Psychosocial Rehabilitation Services (PSR) are rehabilitative behavioral health services that assist individuals in restoring and developing skills necessary for successful functioning in home, school, work, and community settings. PSR focuses on functional skill development and implementation of treatment plan interventions (OAC 5160‑27‑08).

3) Who can provide TBS and PSR?
TBS and PSR must be delivered by qualified behavioral health professionals who are employed or contracted by an Ohio Medicaid‑enrolled provider organization and who meet staff qualification and supervision requirements outlined in Ohio Administrative Code (OAC 5160‑27‑08).

4) What are the billing codes and when is prior authorization required for TBS and PSR?
TBS and PSR are subject to utilization management based on cumulative calendar‑year units. Prior authorization is required after the following thresholds are reached:

• TBS – Individual (H2019): Prior authorization is required after 200 units (50 hours) per calendar year, combined across TBS and PSR.
• TBS – Group (H2019 HQ): Prior authorization is required after 120 units (30 hours) per calendar year.
• TBS Day Treatment – per diem (H2020): Prior authorization is required after 30 units per calendar year.
• PSR (H2017): Prior authorization is required after 200 units (50 hours) per calendar year, combined across TBS and PSR.

When prior authorization is required, requests are reviewed within 7 calendar days, consistent with Ohio Medicaid prior authorization requirements (OAC 5160‑8‑05).

5) What are the medical necessity criteria for TBS and PSR?
TBS and PSR are medically necessary when all of the following apply:

• The individual has documented behavioral, emotional, or functional needs;
• Services are clearly linked to goals and objectives in the individualized treatment plan;
• Interventions are clinically appropriate to address identified needs; and
• Services are not duplicative of other interventions.

TBS focuses on behavioral and emotional interventions, while PSR focuses on restoration and implementation of functional skills. Both services must be delivered consistent with medical necessity standards outlined in Ohio Administrative Code (OAC 5160‑27‑08) and general Medicaid coverage requirements (OAC 5160‑27‑02).

6) When are TBS and PSR reimbursable?
TBS and PSR are reimbursable when they are:

• Medically necessary;
• Authorized under a current individualized treatment plan; and
• Delivered in accordance with Ohio Medicaid service, documentation, and billing requirements (OAC 5160‑27‑02; OAC 5160‑27‑08).

7) What documentation is required for TBS and PSR?
Providers must maintain documentation that includes:

• A current individualized treatment plan;
• Separate progress notes for each service;
• Start and stop times;
• Clinical justification demonstrating medical necessity; and
• Evidence the service is tied to treatment plan goals.

Documentation must support compliance with Ohio Medicaid documentation and coverage requirements (OAC 5160‑27‑02; OAC 5160‑8‑05).

8) Are exceptions ever allowed?
Exceptions to prior authorization thresholds or daily unit limits may be approved on a case‑by‑case basis by Utilization Management when supported by clear clinical documentation and medical necessity (OAC 5160‑8‑05).

9) Where can providers find utilization management thresholds?
Utilization management thresholds and authorization timelines are defined in Appendix A, Table A‑1: New Services Subject to Utilization Management and apply across all provider guidance documents.

10) Who should providers contact with questions?
Providers may contact:

• Buckeye Health Plan Provider Services at 866‑296‑8731, or
• Their assigned Provider Engagement Administrator for questions related to TBS or PSR coverage, authorization, or billing.

This FAQ is intended as guidance and does not replace Ohio Medicaid rules or provider contract requirements.

This Frequently Asked Questions (FAQ) document provides guidance on coverage, prior authorization, documentation, and billing requirements for Community Psychiatric Support Treatment (CPST) and Psychosocial Rehabilitation Services (PSR).

The information below aligns with Ohio Medicaid requirements and Buckeye Health Plan utilization management standards. Governing rules include:

• OAC 5160 27 02 (Coverage and limitations)
• OAC 5160 27 08 (Mental health TBS and PSR)
• OAC 5160 8 05 (Prior authorization standards)

1) What is Community Psychiatric Support Treatment (CPST)?
Community Psychiatric Support Treatment (CPST) is a community based psychiatric support service provided to individuals with a mental health diagnosis and associated functional impairment.

CPST focuses on:

• Ongoing symptom monitoring and support
• Skill development related to daily living
• Crisis prevention and stabilization
• Coordination with the individualized service plan (ISP)
• Advocacy and linkage to community resources

CPST services must be clinically appropriate, medically necessary, and clearly tied to treatment plan goals, consistent with OAC 5160 27 02 and OAC 5160 27 08.

2) What is Psychosocial Rehabilitation Service (PSR)?
Psychosocial Rehabilitation (PSR) is a rehabilitative behavioral health service designed to help individuals restore and improve skills necessary for independent living, social integration, and recovery.

PSR focuses on:

• Skill restoration and skill implementation
• Development of coping strategies and routines
• Community integration and role functioning
• Rehabilitation of functional deficits related to mental illness

PSR interventions must be goal directed, non duplicative, and supported by the individualized treatment plan, in accordance with OAC 5160 27 08.

3) Are CPST and PSR covered services?
Yes. CPST and PSR are covered Ohio Medicaid services when all of the following are met:

• The member has a qualifying mental health diagnosis
• Services are medically necessary
• Services are clearly linked to ISP goals
• Services are delivered by qualified providers

These coverage requirements are defined under OAC 5160 27 02 and OAC 5160 27 08.

4) When is prior authorization required for CPST?
Prior authorization is required after the following calendar year thresholds are exceeded:

• CPST Individual (H0036):
  o   After 200 units (50 hours) per calendar year
• CPST Group (H0036 HQ):
  o   After 120 units (30 hours) per calendar year

Authorization thresholds are applied in accordance with OAC 5160 27 02(B).

5) When is prior authorization required for PSR?
Prior authorization is required for PSR (H2017) after:

• 200 units (50 hours) per calendar year, combined with Therapeutic Behavioral Services (TBS)

This combined threshold reflects ODM’s authority to limit amount, scope, and duration of services under OAC 5160 27 02(B).

6) What does “combined threshold” mean?
A combined threshold means that units from multiple rehabilitative services are added together when determining whether prior authorization is required.

For example:

• Units billed for PSR (H2017) and TBS (H2019) are combined.
• Once the combined total reaches 200 units in a calendar year, prior authorization is required for continued services.

7) What is the prior authorization decision timeframe?
For CPST and PSR services requiring authorization:

• Authorization determinations are issued within 7 calendar days, consistent with Ohio Medicaid prior authorization standards under OAC 5160 8 05.

8) What documentation is required for CPST and PSR?
Providers must maintain documentation that includes:

• Separate progress notes for each service
• Clear linkage to ISP goals
• Clinical justification and progress toward goals
• Evidence of non duplication with other services

These expectations align with OAC 5160 27 08 and Buckeye audit standards.

9) What should providers do to avoid service disruptions?
Providers should:

• Monitor cumulative units throughout the calendar year
• Submit authorization requests before thresholds are exceeded, when possible
• Ensure treatment plans clearly support service intensity and duration

10) Where can providers find utilization management thresholds?
Utilization management thresholds and authorization timelines are defined in Appendix A, Table A‑1: New Services Subject to Utilization Management and apply across all provider guidance documents.

11) Who should providers contact with questions?
Providers may contact:

• Buckeye Health Plan Provider Services at 866‑296‑8731, or
• Their assigned Provider Engagement Administrator

Provider Services can assist with questions related to coverage, prior authorization, billing, and documentation requirements. Provider Engagement Administrators can support provider education, outreach, and escalation of operational concerns.

This FAQ is intended as guidance and does not replace Ohio Medicaid rules or provider contract requirements.

This Frequently Asked Questions (FAQ) document is intended to help providers understand coverage, prior authorization, documentation, and billing requirements for Substance Use Disorder (SUD) Intensive Outpatient Program (IOP) services. The information below aligns with Ohio Medicaid requirements and Buckeye Health Plan utilization management standards.

Governing rules include: OAC 5160‑27‑02, 5160‑8‑05, and 5160‑27‑09, and the ASAM Criteria (latest edition).

1) What is Intensive Outpatient Program (IOP)?
IOP is a structured substance use disorder treatment service that delivers multiple hours of clinically supervised therapeutic services per day, on multiple days per week, without requiring 24‑hour inpatient care. IOP meets ASAM Level 2 criteria and is reimbursed under Ohio Medicaid as a covered SUD level of care (OAC 5160‑27‑09).

2) Who is eligible for IOP services?
Members may be eligible for IOP when they:

• Have a diagnosed substance use disorder;
• Meet ASAM Level 2 criteria based on a multidimensional assessment (OAC 5160‑27‑09); and
• Require structured, scheduled treatment services to support stabilization, recovery, and relapse prevention.

IOP must be clinically appropriate and represent the right level of care, meaning it is not more or less intensive than necessary (OAC 5160‑27‑02; ASAM Criteria).

3) What is the billing code for IOP?
IOP services are billed using:

• H0015 – Alcohol and/or drug services; intensive outpatient treatment (per diem)

IOP is reimbursed as a per diem and includes program‑hour services delivered as part of the structured IOP schedule, consistent with Ohio Medicaid reimbursement policy (OAC 5160‑27‑09).

4) When is prior authorization required for IOP?
Prior authorization is required for IOP services after 30 units per calendar year, in accordance with Buckeye Health Plan utilization management policy and Ohio Medicaid prior authorization requirements (OAC 5160‑8‑05).

• Authorization requests are reviewed within 7 calendar days.
• Continued stay authorization is based on ongoing medical necessity and continued eligibility under ASAM Level 2 criteria (OAC 5160‑27‑09).

Note: The 48‑hour authorization timeframe applies only to Withdrawal Management services and does not apply to IOP.

5) What services are typically included in IOP?
IOP programs generally include a combination of:

• Group therapy
• Individual counseling
• Psychoeducation
• Skill‑building and relapse‑prevention activities

Services must be structured, scheduled, and delivered as part of the IOP program design, consistent with ASAM Level 2 expectations (OAC 5160‑27‑09; ASAM Criteria).

6) What documentation is required for IOP?
Providers must maintain documentation that includes:

• A current individualized treatment plan (ITP) supporting the need for IOP;
• Evidence the member meets ASAM Level 2 admission and continued stay criteria (OAC 5160‑27‑09);
• Progress notes demonstrating clinical necessity, participation, and response to treatment; and
• Clear start and end dates for the episode of care.

Documentation must support that IOP services are medically necessary and clinically appropriate in accordance with Ohio Medicaid requirements (OAC 5160‑27‑02).

7) Are services allowed concurrently with other SUD levels of care?
No. IOP cannot be billed concurrently with another mutually exclusive SUD level of care, such as residential treatment or partial hospitalization, unless explicitly allowed under Ohio Medicaid policy (OAC 5160‑27‑09; ASAM Criteria).

8) Are exceptions ever allowed?
Exceptions to coverage rules or limits may be approved on a case‑by‑case basis by Utilization Management when supported by clear clinical documentation and medical necessity (OAC 5160‑8‑05).

9) Where can providers find utilization management thresholds?
Utilization management thresholds and authorization timelines are defined in Appendix A, Table A‑1: New Services Subject to Utilization Management and apply across all provider guidance documents.

10) Who should providers contact with questions?
Providers may contact:

• Buckeye Health Plan Provider Services at 866‑296‑8731, or
• Their assigned Provider Engagement Administrator for questions related to IOP coverage, authorization, or billing.

This FAQ is intended as guidance and does not replace Ohio Medicaid rules or provider contract requirements.