The Ohio Department of Medicaid is issuing a statement of clarification for community behavior health and SUD treatment providers regarding same day billing of per diem services, specifically IOP (H0015) or PHP (H0015 TG) and TBS Day Treatment per diem (H2020). To receive reimbursement for IOP/PHP and TBS Day Treatment per diem to one individual on the same day, prior authorization is required per OAC 5160-27-06 Therapeutic behavioral group service – hourly and per diem, as stated below:
(C) Limitations.
(2) For adults, reimbursement for the following medically necessary behavioral health group services will be limited to no more than four fifteen-minute units, or one hour per day on the same day as the therapeutic behavioral group service (hourly, or per diem) except when prior authorized.
(a) Group psychotherapy for mental health or substance use disorder diagnoses.
(b) Group therapeutic behavioral services as defined in rule 5160-27-08 of the Administrative Code.
(c) SUD group counseling.
(d) Group community psychiatric supportive treatment.
To clarify, “SUD group counseling” includes the following services: SUD group counseling (H0005), IOP group counseling (H0015), and PHP group counseling (H0015 TG). Because IOP and PHP are group services that exceed one hour in duration, an approved authorization is required for reimbursement of either service on the same day as TBS Day Treatment per diem. This clarification is based on language in existing rule therefore not considered a new application of utilization management. There is no exclusion in the population of Medicaid enrollees to whom this limit applies.
ODM would like to remind SUD treatment providers that OAC 5160-27-09 Substance use disorder treatment services aligns with ASAM practice standards, which “declares the expectation that SUD programs should be co-occurring capable given the prevalence of mental health issues within this population” (ASAM volume 3, Chapter 2, pg. 22). OAC specifically incorporates this requirement into the language for ASAM Level of Care 2, as stated below:
(2) LOC 2: intensive outpatient/partial hospitalization including LOC 2 withdrawal management (WM). LOC 2 services are capable of meeting the complex needs of people with addiction and co-occurring conditions. They can be rendered during the day, before or after work or school, in the evening, and/or on weekends.
For individuals with a co-occurring mental health condition, the SUD provider must be able to address those needs within the construct of the LOC 2 programming. The minimum duration for SUD IOP is 2 hours and 1 minute. The minimum duration for SUD PHP is 3 hours and 1 minute. Both services should extend beyond that duration if necessary to meet overall treatment needs of the individual and to meet the cumulative service hour requirement for the corresponding level of care. For SUD IOP, the requirement is 9-19 hours per week and for SUD PHP, the requirement is 20 or more hours per week.
It is imperative that SUD providers conduct comprehensive and accurate assessment and treatment planning that is inclusive of the presenting need and co-occurring conditions for each patient. If the individual presents for SUD treatment and upon assessment an SUD diagnosis and clinical justification for SUD treatment is confirmed, the clinical recommendation should be placement in an SUD treatment program commensurate with the appropriate LOC.
