Important Update: ODM Utilization Management Requirements Effective July 1

Dear Providers-

This notification is to inform community behavioral health providers of new utilization management policies approved by the Ohio Department of Medicaid (ODM). This action is taken in response to a sustained and statistically significant increase in the utilization of community behavioral health services across all Medicaid populations. This growth, while reflective of expanded access, has surfaced concerns about systemwide gaps which may fail to catch overutilization or layering of multiple services without coordinated clinical oversight. Following extensive feedback from provider associations and managed care plans, this action is intended to ensure that Medicaid members receive appropriate care and to establish necessary guardrails that uphold integrity across the service continuum.

The authorizations will be implemented as “pass throughs,” which means that an approved authorization will not be required to initiate a service.   If the service limit is reached within the calendar year, an authorization will be required to continue services.   This approach preserves medical necessity review at key intervals and ensures appropriate, intentional, and personalized care for members.

Services newly subject to utilization management include the following:

Table A-1: Permitted Service Authorization Thresholds for SUD and Community BH 

Service Name	Service Code	Service Threshold at which authorization is required	Turn around response time by the plan
Therapeutic Behavioral Service - Individual	H2019	200 units (50hrs) combined TBS or PSR per calendar year	7 days
Therapeutic Behavioral Service -  Group	H2019 HQ	120 units (30hrs) per calendar year	7 days
Therapeutic Behavioral Service Day Treatment – per diem	H2020	After 30 units per calendar year	7 days
Community Psychiatric Support Treatment – Individual	H0036	200 units (50hrs) per calendar year	7 days
Community Psychiatric Support Treatment – Group	H0036 HQ	120 units (30hrs) per calendar year	7 days
Psychosocial Rehabilitation Service	H2017	200 units (50hrs) combined TBS or PSR per calendar year	7 days
SUD Ambulatory Withdrawal Management	H0012 H0014	After 7th consecutive day	48 hours
SUD Intensive Outpatient Program	H0015	After 30 units per calendar year	7 days
SUD Residential Clinically Managed -WM	H0010	After 7th consecutive day	48 hours
SUD Residential Medically Managed -WM	H0011	After 7th consecutive day	48 hours

 

There are some exclusions to which behavioral health rehabilitation services can require authorization because of the chronic nature of severe and persistent mental illness and the vulnerability of many who rely on access to these services.

The Behavioral Health rehabilitation services include:

• Therapeutic Behavioral Service, individual (H2019) & unit-based group (H2019 HQ)
• Community Psychiatric Support Treatment, individual (H0036) & group (H0036 HQ)
• Psychosocial Rehabilitation Service (H2017)

Exclusions to authorization are as follows:

• Crisis Services as indicated by the KX modifier are excluded
• Behavioral Health Nursing rendered in accordance with OAC 5160-27-11 is excluded
• Children and youth enrolled in the OhioRISE plan are excluded
• Children and youth in the custody of a Public Child Welfare are excluded

In addition to the exclusions, the plans are also required to authorize BH Rehabilitation services for a duration of at least 90 days. 

The managed care plans may begin implementation of Utilization Management beginning July 1, 2026, but may choose to enact at a later date.  The plans are required to notify their provider networks of any changes to their clinical care policies that involve use of service authorizations at least 30 days before the effective date. Because this is a new process, utilization prior to July 1 will not count towards the newly established service thresholds.  ODM has directed the Managed Care Plans to collaborate and coordinate their efforts to minimize burden on the provider community.  ODM has strict requirements for plan compliance with allowable methods of authorization submission and timely decision turn-around.  ODM will be conducting reviews to ensure plans are meeting expectations.

ODM is updating the existing community behavioral health and substance use disorder authorization forms to capture additional information necessary to support decision-making for these services.  Those updated forms will be posted on ODM’s Behavioral Health Information for Providers website ahead of the July 1 go-live date.  The Managed Care Plan’s individual utilization management policies will be made available on the ODM website.

We understand this will be a significant operational change for some providers.  ODM and the plans will continue collaboration with the BH provider associations throughout the transition to ensure the provider community has adequate support.  

Thank you,

Ohio Department of Medicaid