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CurrentOptumPolicy BH803OH012025.D

Ohio Medicaid Supplemental Clinical Criteria — Behavioral Health

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State-specific clinical criteria and coverage rules for behavioral health and substance use disorder services for Ohio Medicaid members; used by Optum reviewers and providers to determine medical necessity and service limitations.

Policy Summary

PayerOptum

PolicyOhio Medicaid Supplemental Clinical Criteria — Behavioral Health

Policy CodePolicy BH803OH012025.D

Change TypeNo material changes

Effective DateAug 1, 2025

Last ReviewJun 27, 2025

Next Review Date

Key ActionObtain prior authorization per Ohio Medicaid requirements for services that require PA (e.g., ABA, ACT, LOC2.5, extended peer support, testing beyond limits).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PA overrideLimits may be exceeded with PA

ABA PAPrior authorization required for ABA

≤21ABA supported through age

80%Utilization attention threshold

72 hrsMRSS de-escalation max

6 monthsNo progress reassess interval

Coverage and Medical Necessity Criteria

General coverage criteria

Covered when ALL of the following Ohio Medicaid conditions are met

Core medical necessity: Service meets Ohio medical necessity definition: accepted standards of medical practice; clinically appropriate in type, frequency, extent, duration and setting; appropriate to the condition and expected to produce the desired outcome; lowest cost effective alternative; provides unique diagnostic information if diagnostic; not provided primarily for provider economic benefit.

See OAC rule 5160-1-01

Diagnosis requirement: An ICD-10 diagnosis of mental illness or substance use disorder is documented in the record.

Medicaid recognized diagnoses per Ohio Medicaid guidance

Provider and documentation requirements: Treatment plans and progress notes maintained per OAC rules (5160-01-27; 5160-8-05); treatment plans developed by practitioners meeting OAC practitioner requirements.

Policy Summary

PayerOptum

PolicyOhio Medicaid Supplemental Clinical Criteria — Behavioral Health

Policy CodePolicy BH803OH012025.D

Change TypeNo material changes

Effective DateAug 1, 2025

Last ReviewJun 27, 2025

Next Review Date

Key ActionObtain prior authorization per Ohio Medicaid requirements for services that require PA (e.g., ABA, ACT, LOC2.5, extended peer support, testing beyond limits).

SourceLink

On This Page

Documentation must support medical necessity and treatment goals

Service-specific limits and PA: Services subject to amount/scope/duration limits (e.g., SBIRT, SUD assessments, urine drug screens, peer recovery hours, ACT availability) may be exceeded only with prior authorization per Ohio Medicaid process.

See Ohio Medicaid prior authorization links

Medical necessity and coverage criteria for ABA

Covered when ALL of the following are met

Diagnostic validation: Diagnosis of ASD (or other state‑mandated applicable diagnosis) is validated by a comprehensive diagnostic evaluation completed by a licensed clinician demonstrating DSM-5-TR criteria.

See required diagnostic instruments and assessments

Standardized confirmation: Diagnosis and severity confirmed using standardized screening/diagnostic tools (examples: ABC, CARS/CARS‑2, M‑CHAT, CSBS‑DP‑IT, ADI, ADOS).

At least one validated measure at baseline and repeated regularly

Comprehensive assessment elements: Assessment includes caregiver interviews, direct observation, record review, formal exams of language, cognitive and adaptive abilities, sensory assessment, and evaluation of co‑occurring conditions to inform treatment targets and hours.

Include functional/skills baselines (e.g., VB‑MAPP, ABLLS) as appropriate

Qualified providers and supervision: Treatment provided by credentialed ABA providers (e.g., BCBA or licensed behavioral health clinician) with technicians (e.g., RBT) under appropriate supervision; minimum supervision proportional to dosage (minimum 5% of direct hours supervised).>=5% supervision

BCaBA/non‑licensed may assist under direct supervision; parents should not serve as RBTs

Treatment planning and measurement: Treatment intensity determined by baseline measurement and ongoing measurement using validated tools; number of hours justified by clinical need, level of impairment, developmental needs and treatment history; caregiver engagement and documented training required.

Caregiver involvement ideally >=2 hours/month

Least restrictive setting: Services delivered at the least restrictive, most clinically appropriate level and setting; consider less intensive services (speech, OT, psychotherapy) when clinically indicated.

Focused vs comprehensive ABA chosen based on severity and targets

Initial and Continued ABA treatment criteria

Covered when ALL of the following are met

Diagnostic confirmation: ASD diagnosis validated by a documented comprehensive assessment completed by a licensed clinician demonstrating DSM‑5‑TR criteria.

Includes formal exams and standardized instruments

Baseline assessment and treatment plan: An ABA assessment (including standardized functional assessment and baseline skills measurement) that informs measurable treatment goals, frequency, intensity, duration, caregiver training plan and coordination with other providers is documented.

At least one validated measure used at baseline and repeated at least twice annually

Qualified providers & supervision: Services delivered by credentialed ABA providers (e.g., BCBA) with technicians under supervision; supervision frequency proportional to dosage (guideline up to 2 hours supervision per 10 hours direct treatment), individualized as needed.

Minimum 5% of direct hours supervised

Treatment focus and measurability: ABA targets socially significant behaviors with objective, quantifiable goals, baseline data, measurable progress, projected timeframes; caregiver training must be included and documented.

Data-driven measurement and caregiver participation required

Ongoing review for continued treatment: For continued authorization, updated treatment plan and progress reports must demonstrate reasonable expectation of clinically meaningful improvement using same measurement modes as baseline; lack of progress triggers reassessment and modification.

Document progress per outcome measures and address utilization issues (e.g., <80%)

Transition and discharge planning: Treatment plan must include transition steps toward less intensive services as goals are achieved, plans for generalization/maintenance and booster sessions or caregiver consultation when direct care is reduced.

Treatment plans reviewed/updated typically twice annually

Continued Treatment and Goal Achievement

Continued ABA treatment requires documentation of progress and, if inadequate, specific assessment and treatment modifications; when goals are achieved, the plan must identify new goals or transition steps.

Reassessment triggers: Provider must reassess when inadequate progress on targeted behaviors, no demonstrable progress within a 6‑month period, specific goals not met within estimated timeframes, or utilization of prior authorization period hours below 80% (or <80% over 2 weeks).6 months; <80% utilization

Concurrent review should document barriers and remedies

Required assessment content after inadequate progress: Documentation must include increased time/frequency on targets when applicable, change in treatment techniques, increased caregiver training, identification of barriers and solutions, evaluation for newly coexisting disorders, and plans for generalization and maintenance across environments.

Progress should be documented with standardized adaptive functioning measures

When goals achieved: Either identify new, meaningful goals that address remaining functional deficits or revise the plan to transition to less intensive interventions (e.g., caregiver coaching, booster sessions).

Documented plan for generalization/maintenance required

ABA Discharge Criteria

Discharge should be planned and criteria documented at service initiation and refined over time; discharge occurs when measurable endpoints are met or services no longer benefit the member.

Discharge indicators: Documented improvement from baseline with goals achieved or maximum benefit reached; plateaued or minimal progress despite treatment modifications; lack of substantive progress across successive authorization periods; treatment causing worsening of deficits despite modifications; member unlikely to maintain long‑term gains; caregivers unable or unwilling to follow treatment to extent that compromises effectiveness; or improved functioning indicating no longer need for intensity.

Use standardized assessments (e.g., Vineland) to document progress or plateau

ACT Admission Criteria

Admission to ACT requires all listed conditions be met.

Primary diagnostic and age criteria: Recipient has diagnosis of schizophrenia, bipolar disorder, or major depressive disorder with psychosis (per ICD‑10 group list) and is 18 years or older; recipient has SSI/SSDI determination OR meets ANSA threshold (score >=2 on a 'mental health needs' or 'risk behaviors' item, or score 3 on a 'life domain function' item) assessed by trained evaluator.ANSA >=2 or life domain function =3

ANSA administered by trained assessor with bachelor's degree or higher

Utilization/history criteria (one or more): One or more of: two or more psychiatric inpatient admissions in past 12 months; two or more uses of psychiatric emergency services in past 12 months; significant difficulty meeting basic survival needs in past 24 months; or criminal justice involvement in past two years.

At least one required

Current risk/need criteria (one or more): One or more of: persistent or recurrent severe psychiatric symptoms; coexisting SUD >6 months; resides in inpatient/supervised residence but clinically able for more independent living with intensive services; at risk of psychiatric hospitalization/institutional placement without intensive services; or unsuccessful with traditional outpatient services.

At least one required

ACT Discharge Criteria

Criteria for planned and unplanned disenrollment from ACT.

Planned disenrollment: Recipient reached established goals and recipient/guardian and ACT team agree; recipient moves outside ACT geographic area with arranged transfer; recipient or guardian requests disenrollment; or recipient no longer meets eligibility/medical necessity.

Planned disenrollment requires documentation of reasons, progress, linkage/transfer, and signatures

Unplanned disenrollment: ACT team unable to locate recipient for more than 45 days; recipient incarcerated, hospitalized, or admitted to residential SUD facility; if stay predicted >2 months, recipient shall be disenrolled (teams should maintain contact to assist retransition if return likely within two months).45 days; 2 months

Re-enrollment permitted following eligibility reassessment

Initial Admission

Covered when ALL of the following are met for ACT admission

ACT Admission: Recipient meets diagnostic criteria (schizophrenia, bipolar, or major depressive disorder with psychosis), is age >=18, has SSI/SSDI determination OR meets ANSA thresholds, has one or more specified recent high‑utilization/instability indicators, and meets one or more current risk/need criteria indicating need for intensive multidisciplinary community services.

All grouped elements required; OR logic preserved within nodes

Discharge and Re-enrollment

Discharge / disenrollment conditions

Planned Disenrollment: Recipient reached established goals and recipient/guardian and ACT team agree; recipient moves outside ACT geographic area with arranged transfer; recipient or guardian requests disenrollment; or recipient no longer meets eligibility/medical necessity. Documentation of reasons, progress, linkage, and signatures required.

Unplanned Disenrollment: Recipient cannot be located >45 days; recipient incarcerated, hospitalized, or admitted to residential SUD facility; if anticipated stay >2 months, disenroll; teams should maintain contact to assist retransition if return within two months.45 days; 2 months

Re-enrollment allowed after eligibility determination

Service & Team Requirements

Service delivery, team, and billing coverage rules

Prior Authorization and provider eligibility: Prior authorization required from ODM designated entity before rendering ACT services; PA requests must include ANSA or documentation supporting SSI/SSDI determination; provider must meet OAC eligibility and employ ACT treatment teams.PA required; PA period up to 12 months

Maximum prior authorization period is 12 months

Team structural requirements: Each ACT team must complete DACTS fidelity review in year one and annually thereafter; have a designated full‑time team leader (NPI, enrolled Medicaid provider) with specified licensure; employ multidisciplinary mental health and SUD practitioners and meet peer recovery supporter criteria when used.annual fidelity review

Team leader may serve only one team

Billing unit limits: Providers may bill up to four ACT units per recipient per month when clinical and billing requirements are met. Limits by provider category apply: one unit per month for medical prescriber; one unit per month for listed licensed clinicians; up to two units per month for trainees/assistants/peers/QMHS.<=4 units/month

Prescriber must have at least one contact every three months

Service exclusivity & documentation: When enrolled on ACT, no other Medicaid community behavioral health services are reimbursable except supported employment under specialized recovery services, certain SUD services outside ASAM level one, and crisis services by other providers; treatment plans must be individualized, cover key areas, reviewed at least every six months, and signed by recipient and ACT practitioner.treatment plan review >= every 6 months

Documentation must meet OAC rules 5160-1-27 and 5160-8-05

Behavioral Health Nursing Coverage

Behavioral health nursing services are covered when ALL of the following are met

Definition and eligible providers: Services performed by RNs or LPNs within their professional scope as defined in ORC 4723.01 and OAC rules 5160-27-11 and 5160-27-01; intended to address behavioral and physical health needs of individuals in psychiatric or SUD treatment.

Eligible providers: RN, LPN

Covered activities: May include health screenings, nursing assessments/exams, vital signs, monitoring medication effects, symptom monitoring, behavioral health education, collaboration with individual/family, and group nursing services (group nursing must be RN).

Group nursing must be RN

Coverage limitations: Group nursing and nursing assessments must be RN; medication administration by same practitioner to same recipient on same day is not separately reimbursable; behavioral health nursing not reimbursable when recipient enrolled in ACT or SUD residential; group nursing cannot be provided same day as residential treatment, ambulatory detox, or IOP for SUD; documentation rules apply.

Adhere to OAC documentation rules

Covered peer support services

Peer support services are covered when ALL of the following are met:

Rendered per rule and as component of behavioral health treatment: Provided in accordance with activities described in OAC rule 5122-29-15 and delivered as a component of behavioral health treatment addressing the individual's mental health or SUD needs.

Activities include recovery support, system navigation, advocacy, crisis support

Treatment plan requirement: Services intended to achieve goals/objectives documented in a current individualized treatment plan meeting rule 5122-27-03.

Must be linked to measurable goals in the treatment plan

Service modalities and settings: May be provided to individuals, families, or groups in locations that meet recipient needs (community, home, etc.); provided by certified peer supporter per OAC rule 5122-29-15.1.

Prior authorization required if >4 hours to same individual on same date

Covered behavioral health respite services

Behavioral health respite coverage conditions:

Authorization and plan inclusion: OhioRISE behavioral health respite must be authorized by the OhioRISE plan and identified on the youth's child and family-centered care plan.

Authorization per rule 5160-59-03.4

Caregiver need: Coverage is based on determination that the youth's primary caregiver has a demonstrated need for temporary relief due to the youth's behavioral health needs.

Amount, scope, and duration consistent with youth's needs

Settings and activities: Short‑term respite may be provided in‑home or specified community settings (licensed foster home, crisis house, emergency shelter, out‑of‑home crisis stabilization) and may include activities of daily living and transportation as part of service.

Provider awake requirements documented when youth awake for overnight respite

Acupuncture coverage

Acupuncture is a covered benefit when ALL of the following are met:

Acupuncture coverage criteria: Service is medically necessary per OAC rule 5160-1-01; performed in accordance with Ohio Revised Code sections 4762.10 or 4762.01; and rendered only for listed conditions: low back pain, migraine, cervical/neck pain, osteoarthritis of hip, osteoarthritis of knee, nausea/vomiting related to pregnancy or chemotherapy, or acute post‑operative pain.

Delivered by eligible providers per OAC 5160-8-51

Skilled therapy coverage

Skilled therapy services are covered when ALL of the following are met:

Skilled therapy coverage criteria: Service is medically necessary per OAC rule 5160-1-01; delivered by eligible providers per OAC 5160-8-35; amount, frequency, and duration reasonable; based on clinical evaluation/assessment and provided according to a documented treatment or maintenance plan; delivered in response to prescription (PT/OT) or referral (SLP) except as noted for school program services.

Reevaluation intervals: rehabilitative 30–60 days; developmental 30 days–6 months

Unproven complementary and alternative modalities

The following complementary and alternative modalities are considered unproven and not medically necessary for behavioral and substance use disorders:

Unproven/Not medically necessary modalities: Acupuncture (for BH/SUD indications other than listed covered conditions), animal‑assisted therapy, art therapy, dance/movement therapy, equine therapy, music therapy, naturopathic detoxification, and sauna/niacin detoxification are considered unproven and not medically necessary for BH/SUD treatment due to insufficient evidence.

Policy lists these as unproven for BH/SUD treatment

CBTCBT — Not Medically Necessary

Coverage stance for CBTCBT in outpatient SUD treatment:

CBTCBT Not Medically Necessary: Computer‑based cognitive behavioral therapy (CBTCBT) is unproven and not medically necessary as a stand‑alone outpatient therapy to treat substance use disorders.

Limited evidence for adjunctive use only; must be provided by or under direction of qualified behavioral health provider

CBTCBT — Adjunctive Use

Adjunctive or limited use conditions:

Adjunctive Evidence: Limited evidence supports CBTCBT (e.g., reSET®/reSET‑O®) as an adjunct to standard outpatient treatment; if used adjunctively, it must be under direction of a qualified behavioral health provider and consistent with the member's benefit document.

reSET® is a 12‑week PDCT and not intended as stand‑alone for opioid dependence

Community Psychiatric Supportive Treatment (CPST)

CPST service intent and covered activities:

CPST Purpose: Provide individualized, measurable community‑based services to support community functioning, independence, and integration for adults, children, adolescents and families; services vary by hours, type, and intensity per individual needs.

Focus on ISP goals and community functioning

CPST Service Activities: Activities may include ongoing assessment, assistance with basic needs and daily living skills, coordination of ISP and linkages to supports, symptom monitoring, crisis management/stabilization, advocacy/outreach, education/training, and interventions to remove barriers to education/employment.

Enumerated list per policy

Community Psychiatric Supportive Treatment (CPST)

CPST services are covered when provided according to Ohio rules and individualized service plan requirements and when medically necessary.

CPST general coverage criteria: Services address individualized mental health needs, are identified in the ISP, include activities such as assessment, daily living skills development, symptom monitoring, coordination of ISP, crisis management, advocacy, and targeted mental health interventions that remove barriers to functioning; provided by staff qualified per OAC with a designated case coordinator.

Delegation to non‑certified entities requires written agreements and documentation of staff development plans

Mental Health Day Treatment

Mental health day treatment is covered when clinically indicated with clear admission and discharge criteria, individualized treatment plans, and documentation of medical necessity.

Day Treatment core criteria: Program is intensive, structured, goal‑oriented, meets accrediting body standards, provides 2–7 hours of scheduled intensive activities per program day, maintains appropriate staff‑to‑client ratios, and documents medical necessity in the medical record.Program day 2–7 hours

Treatment plans and documentation must meet OAC requirements

Electroconvulsive Therapy (ECT)

ECT is covered when medically necessary for severe, treatment‑resistant depression and select bipolar or schizophrenia cases not responsive to other treatments; prior notification required for scheduled inpatient admissions.

ECT indications: Medically necessary for severe, treatment‑resistant major depressive disorder; may be useful for refractory bipolar disorder and schizophrenia when other treatments have failed; administered by privileged psychiatrist with anesthesia/nursing support.

Prior authorization/notification for scheduled inpatient admissions at least 5 business days prior

ECT exclusions: ECT is not medically necessary for multiple‑seizure electroconvulsive therapy (MECT) and for diagnoses other than major depressive disorder, bipolar disorder, or schizophrenia (examples include SUD, ASD, OCD, PTSD).

Failure to notify Optum of inpatient admission with ECT may reduce benefits per member plan

SUD Day Treatment / IOP (ASAM)

SUD day treatment/IOP services are provided according to ASAM criteria and require prior authorization for certain levels.

ASAM-based SUD Day Treatment/IOP: Services follow ASAM criteria for admission, continued stay and discharge; LOC1 outpatient limits (<9 hrs/week adults; <6 hrs/week adolescents); LOC2.5 (partial hospitalization) requires prior authorization with minimum 20 hours/week; if after 4 consecutive weeks services are <20 hours/week, PA is rescinded and reimbursement may be at a lower LOC not to exceed 19.9 hrs/week.LOC2.5 >=20 hours/week

Document medical necessity in record per OAC rules

ECT — Covered and Not Medically Necessary Conditions

ECT coverage and medical necessity

ECT Medical Necessity: ECT is medically necessary for severe, treatment‑resistant depression and may be useful for refractory bipolar disorder and schizophrenia not responsive to other treatments.

Administered with appropriate anesthesia and psychiatric privileges

ECT Not Medically Necessary: ECT not medically necessary for MECT or for diagnoses other than major depressive disorder, bipolar disorder, or schizophrenia (e.g., SUD, ASD, OCD, PTSD).

Coverage subject to member benefit document

IMD/Inpatient Coverage Criteria and Limits

IMD and Inpatient behavioral health coverage

IMD admission age: Member must be age 21 to 64 to be admitted to an IMD setting.age 21-64

IMD length limit: Limit of 15 days per month for IMD inpatient psychiatric or SUD treatment when billed under 42 CFR 438.6(e).<=15 days/month

IMD exclusions: Ohio Medicaid does not cover services for certain populations in IMDs except as permitted under 42 CFR 438.6(e) or CMS‑approved waivers; suspension rules apply for inmates per SUPPORT Act provisions.

EPSDT (Healthchek) — Pediatric Coverage

EPSDT coverage: Healthchek/EPSDT covers screening, diagnostic, and medically necessary treatment services to correct or ameliorate conditions for Medicaid recipients under age 21; coverage limits may be exceeded with prior authorization when medically necessary.age <21

Follow OAC 5160-1-14 and EPSDT guidance

Initial MRSS Admission Criteria

MRSS is provided when ALL of the following are met:

Age: Person is under twenty‑one years of age.<21

Location and modality: Service intended to be delivered in‑person where youth/family are located; telehealth permitted in limited circumstances (family request, contagious condition, inclement weather).

Response time and initiation: Initial mobile response expected within 60 minutes from end of initial call (or within 48 hours if caller requests later response); de‑escalation up to 72 hours and stabilization up to 42 days; documentation required if response >60 minutes.<=72 hours de‑escalation; <=42 days stabilization

Ohio MRSS state line and dispatch process

Screening/triage initiation: MRSS initiated via screening/triage (direct provider connection or statewide call center) with initial remote triage to gather crisis info and determine response; all non‑911 crisis calls receive mobile response.

MRSS Team Composition

MRSS Team Composition — ALL required:

Clinician: A clinician per OAC rule 5122‑29‑30 with valid and unrestricted Ohio license/certification and competency with under‑21 population; a QBHS alone does not meet the standard.

Independently licensed supervising practitioner acceptable

Second team member options: Either a family peer or youth peer supporter with OhioMHAS certification and competency in under‑21 care OR a QBHS demonstrating competency in under‑21 care.

Psychiatric consultation access: Team must have ready access to a psychiatrist or certified nurse practitioner/clinical nurse specialist for consultation (not necessarily team member) licensed in Ohio.

Mobile Response Activities

Mobile response activities — DURING de‑escalation (up to 72 hours):

Urgent assessment: Assess precipitating events, family/youth responses, risk of lethality/violence, medical/physical status including substance use, mental status, strengths, coping skills and social supports.

Initial safety plan: Develop an initial safety plan to provide at first face‑to‑face contact.

Crisis interventions: Provide crisis intervention and de‑escalation including risk assessment, safety planning, coping/behavior management teaching, mediation, parent support, and psychoeducation.

Telephonic psychiatric consult and CANS administration when indicated

Psych consult and CANS: Telephonic psychiatric consultation when indicated; administer Ohio children's brief CANS prior to stabilization phase or when adequate information available for those not continuing into stabilization.

Qualified CANS assessor required

Stabilization Services

Stabilization services — FOLLOWING de‑escalation and per individualized MRSS plan:

Plan implementation: Provide continued monitoring, coordination, and implementation of individualized MRSS plan to achieve youth/family goals.<=42 days per individualized MRSS plan

Stabilization activities: Include psychoeducation, referral for psychiatric consultation/medication management, advocacy/networking for community linkages, coordination of services to address needs.

Linkage and planning: Link to natural and clinical supports to maintain engagement post‑MRSS and convene planning meetings with cross‑system partners as indicated.

Service Transition

Service transition requirements:

Transition planning: MRSS team and youth/family prepare a transition plan documenting supports/resources, include most recent individualized MRSS plan and safety plan.

Document transition and supports

Information sharing: With permission, team will share MRSS plan and supporting information with other providers (in person or via video/telephone) with youth/family present when possible.

Admission and Respite Authorization

Admission and eligibility criteria for OhioRISE and authorization conditions for behavioral health respite

OhioRISE admission criteria: Be enrolled in Ohio Medicaid; be under age 20; be at risk for or have had behavioral health hospitalization or ED visits with psychiatric diagnosis; meet CANS criteria determined by qualified assessor.age <20

Enrollment begins on CANS submission date; urgent cases may enroll on inpatient/PRTF admission date

CANS process steps: Referral to CANS assessors within 1 business day; assessment within 72 hours; assessment reviewed within 10 business days; enrollment begins on CANS submission date.72 hours; 10 business days

Multiple referral pathways exist

Behavioral health respite authorization criteria: Respite coverage subject to OhioRISE plan authorization per OAC rule; amount, scope, and duration consistent with youth's needs and behavioral health history; primary caregiver must demonstrate need for temporary relief; respite identified on child/family care plan.

Provider awake requirements documented for overnight respite

Respite Limitations and Exclusions

Limitations, locations, and funding exclusions for behavioral health respite

Residence and provider limitations: Reimbursement allowed when youth resides with primary caregiver in a home not owned/leased/controlled by a provider, in ODJFS‑licensed foster home, in home of kin, or in medically fragile/treatment foster home; respite not reimbursable if room and board covered by Medicaid or Title IV‑E used for coverage; respite must not duplicate other foster respite reimbursement.

Permitted delivery locations: Primary caregiver's home (not owned/leased/controlled by provider); qualifying provider's residence with guardian approval; licensed foster home; home of kin; treatment foster home certified by ODJFS; community settings open to public.

Provider awake when youth awake for overnight care

Behavioral health respite — Coverage criteria

Behavioral health respite — Covered when ALL of the following are met

Respite location and enrollment: Member is enrolled in OhioRISE and resides in qualifying setting (primary caregiver's home not owned/leased/controlled by a provider; ODJFS‑licensed foster home; kin home; medically fragile or treatment foster home).

Reimbursement allowed only in these settings

Behavioral health need: OhioRISE plan determines behavioral health respite need based on youth's behavioral health needs and history.

Respite amount/scope/duration authorized by OhioRISE

Payment restrictions in foster settings: Respite reimbursable in foster/treatment foster homes only if it meets rule provisions, does not duplicate other available respite reimbursement, Medicaid does not cover room and board, and Title IV‑E is not used for coverage.

Intensive Home-Based Treatment (IHBT) — Admission Criteria

IHBT — Covered when ALL of the following are met:

SED determination: Clinically determined to meet Serious Emotional Disturbance (SED) criteria per OAC rule 5122‑2401.

Documented by IHBT team in ICR

Age: Member is under 21 years of age.<21

Mental health need and CANS severity: Ohio‑specific CANS indicates marked to severe behavioral/emotional impairment and at least one of: impairment seriously disrupts functioning or actionable risk behaviors on CANS.marked to severe

Placement/risk conditions: One or more of: at risk for out‑of‑home placement due to behavioral health conditions; returned from out‑of‑home placement within previous 30 days or transitioning back within 30 days; requires high intensity interventions to safely remain/return home. Must be documented in ICR.

IHBT — Service Components

IHBT service elements — Conditions for service delivery:

Intensity and contacts: Multiple face‑to‑face contacts per week with child/adolescent and family (including collateral contacts); frequency may fluctuate based on assessed needs and documented in ICR.

Setting and availability: Provided in home, school and community; immediate crisis response available 24/7 by lead IHBT team member with back‑up; providers available evenings/weekends as needed; service is time‑limited and individually tailored.

Assessment and safety planning: Each child/family assessed for risk and safety; jointly written safety plan when clinically indicated; transition plan to other services required.

Opioid Treatment Program — Medication Administration and Staffing

Opioid Treatment Program — Medication administration and staffing covered when ALL operational and clinical safeguards are met:

Medication route and privacy: Methadone must be administered or dispensed only in oral liquid doses and medication administration provided to ensure privacy.oral only

Face‑to‑face interactions required

Administration personnel: Medication administration performed by licensed physician, pharmacist (per consult agreement), registered nurse, LPN with approved med administration course, or PA with approved course; supervised by physician or RN.

Prescriber must be staff or contract employee of OTP

Prescriber order and record: A written, signed, and dated prescriber's order is required and maintained in patient record for all medication administered; prescriber's orders valid maximum 90 days and must be reviewed at least every 90 days.90 days

Orders and take‑home authorizations documented in record

PRTF Admission

PRTF admission is covered when ALL of the following are met:

PRTF admission criteria: Child under 21 with significant functional impairment from behavioral health condition; services provided under physician direction; facility meets applicable accreditation/state survey requirements; certified in writing as necessary; team certifies community ambulatory resources insufficient and inpatient care required; services expected to improve condition or prevent regression.age <21

Certification processes and timelines depend on admission type

PRTF Continued Stay

Continued stay requires active treatment:

Active treatment and plan of care: Active treatment implemented via an individual plan of care developed and implemented no later than 14 days after admission and designed to achieve discharge at the earliest possible time.14 days

Individual plan of care must be interdisciplinary and meet OAC content requirements

OTP Medication-Assisted Treatment

OTP medication‑assisted treatment and take‑home rules — covered when ALL operational and clinical safeguards are met

Medication administration format: Medication administration must be face‑to‑face; methadone administered orally in liquid doses; labels and dispensing comply with federal and state pharmacy rules; privacy ensured.

Follow 21 C.F.R. and Ohio pharmacy rules

Staffing and credentials: Medication administration/dispensing by appropriately credentialed staff (licensed physician, pharmacist per consult agreement, RN, LPN with approved course, or PA with approved course); prescriber must be staff or contract employee of OTP; supervision by physician or RN required.

Written prescriber order required

Prescriber orders and renewal: Prescriber's order valid maximum 90 days; reviewed at least every 90 days and adjusted/reordered or discontinued; take‑home orders expire every 90 days.90 days

Individualized rationale for take‑homes documented

Take‑home dosing limits: During first 90 days of methadone treatment, take‑home limited to single dose each week; for partial agonists first 90 days limited to 14‑day supply; after 90 days take‑home may not exceed one month; no take‑homes for short‑term detox except Sundays/holidays if program closed.first 90 days limits

Medical director may authorize additional holiday dose with documentation

Interim maintenance exceptions: Interim maintenance follows comprehensive maintenance requirements except limited take‑homes for methadone (Sundays/holidays only), no primary counselor required, some rehabilitative services not required; interim maintenance max 120 days in 12 months and reserved when comprehensive maintenance unavailable within 14 days.<=120 days per 12 months

Initial and additional toxicology screens recommended

Continued Stay / Individual Plan of Care

Continued inpatient psychiatric services are covered when active treatment and plan‑of‑care requirements are met.

Inpatient continued stay criteria: Active treatment with an individual plan of care developed and implemented no later than 14 days after admission and designed to achieve discharge as early as possible.14 days

Plan reviewed every 30 days

Plan of care content and team: Plan based on diagnostic evaluation across medical/psychological/social/behavioral/developmental domains; states treatment objectives; prescribes integrated therapies and post‑discharge coordination; developed by interdisciplinary team and reviewed every 30 days.30 days

Team includes required professional disciplines

Minimum team composition: Team must include at minimum a board‑eligible/certified psychiatrist and clinical psychologist with physician involvement or equivalent physician with psychiatric specialization plus other core disciplines (psychiatric social worker, RN with specialized training, occupational therapist, or master‑level psychologist) as specified.

Interdisciplinary team required

Testing Medical Necessity and Limits

Testing medical necessity and limits — Coverage for psychological and neuropsychological testing is conditional and limited:

Appropriate indications: Testing appropriate to measure intellectual, cognitive, emotional and behavioral functioning, identify psychopathology, adaptive skills, or when changes in mental illness require new diagnoses or treatment changes.

Testing indicated by change in clinical status

Repeat testing not required for routine diagnosis or continued treatment is medically unnecessary; nonspecific behaviors without indication of mental illness are not acceptable indications.

Testing should be clinically justified

Coverage limits: Psychological testing: maximum 12 hours per recipient per calendar year; Neuropsychological testing: maximum 8 hours per recipient per calendar year; limits may be exceeded only with prior authorization from the ODM designated entity.12 hours (psych); 8 hours (neuropsych) per year

Prior authorization required past 20 hours/encounters per year

Tele-assessment Coverage Criteria

Tele‑assessment rules for psychological testing:

Standard of care and exceptions: Face‑to‑face assessment is the standard; tele‑assessment may be allowed case‑by‑case when in‑person testing unavailable or to extend reach, provided professional and ethical standards and test integrity are maintained.

Consult member benefit document and licensure rules

Tele‑assessment denial conditions: Tele‑assessment is not covered if in‑person testing is available, provider not proficient in telehealth, provider not licensed in the state where member receives testing, HIPAA‑compliant platform not used, test materials not secured, inadequate audio‑visual monitoring, member unsuitable for remote administration, technology/access/literacy barriers, test selection invalid for remote administration, or informed consent for telehealth testing not obtained.

Examples and platforms listed in policy

Ohio Medicaid identifies explicit categories of services that are not covered and therefore not reimbursable. Examples include educational, vocational, or job training services; room and board; habilitation services (e.g., supportive housing, supportive employment, basic skill acquisition that are habilitative in nature); services provided to recipients held in public institutions or to residents of institutions for mental disease; and recreational and social activities such as art, music, and equine therapies. Transportation for the recipient or family is also listed as non-reimbursable. These exclusions are referenced in the Ohio Administrative Code and reflect limits on federal financial participation for certain institutionalized populations.

Applied Behavior Analysis (ABA) is not covered when program elements fail to meet the policy's ABA criteria. Specifically, coverage is denied for programs or interventions that do not satisfy the stated clinical criteria, those not delivered by or under supervision of an ABA‑trained professional, and programs that target diagnoses other than autism spectrum disorder unless otherwise mandated. The policy also emphasizes that ABA must be provided at the least restrictive, clinically appropriate level and that parent/caregiver involvement is required but parents should not function as technicians; programs that do not meet these supervision, provider qualification, or program delivery requirements are excluded from coverage.

Parent support groups and peer‑led support meetings are explicitly identified as not medically necessary. While caregiver training and involvement in ABA programs are required and encouraged, standalone parent support groups (without individualized, measurable treatment objectives provided by qualified practitioners) are not considered medically necessary services for reimbursement.

The inclusion of a CPT, HCPCS, or other procedure or diagnosis code in this policy document is for reference only and does not itself confer coverage. Whether a service represented by a listed code is payable depends on the member's specific benefit plan, applicable laws, and other contractual rules; listing a code does not guarantee reimbursement.

Certain activities are explicitly non‑reimbursable when billed as behavioral health services. Examples include time spent in recreational activities, academic tutoring or teaching of school subjects, habilitative skill acquisition that is not part of a covered treatment, childcare or respite billed outside authorized respite rules, and transportation for recipients or families (except as part of authorized respite or when explicitly allowed). Group nursing or other services must meet RN‑delivery and documentation rules to be reimbursable; otherwise they may be excluded.

Prior Authorization, Documentation, and Billing Actions

Prior Authorization

Prior authorization may exceed stated service limits

Certain service limits (for example SBIRT frequency, ACT start date, CPST scope, SUD partial hospitalization/residential limits, and psychological/neuropsychological testing hour limits) may be exceeded through prior authorization per Ohio Medicaid rules; providers must use ODM prior authorization links to request exceptions.

Examples of limits that can be exceeded with PA: SBIRT (one per code per provider/year), ACT start date tied to PA approval, CPST scope, SUD LOC2.5/partial hospitalization/residential limits, and testing hour limits (psychological 12 hrs / neuropsych 8 hrs).
Use the Ohio Department of Medicaid consolidated prior authorization links for current PA processes: https://medicaid.ohio.gov/resources-for-providers/billing/prior-authorization-requirements/prior-authorizationrequirements.

Prior Authorization

Prior authorization required for all ABA codes

Prior authorization is required for all covered applied behavior analysis (ABA) codes for both initial and concurrent reviews; follow Ohio Department of Medicaid consolidated prior authorization links for current submission processes.

PA required for initial and concurrent ABA reviews.
PA submissions should reference ODM prior authorization resources for up-to-date requirements.

Prior Authorization

Include detailed treatment plan and clinical justification with PA

Prior authorization requests and continued-review submissions for ABA must include a treatment plan that specifies setting, instructional methods, hours requested, schedule, and clinical justification; concurrent reviews require updated treatment plans and progress reports.

Treatment plan must indicate treatment setting, instructional methods, hours requested, schedule, and clinical justification of those hours.
Continued authorization requires updated treatment plan and progress reports documenting measurable progress toward goals.

Prior Authorization

Follow Ohio Department of Medicaid PA processes and links

Providers must follow Ohio Medicaid prior authorization requirements as posted by the Ohio Department of Medicaid (ODM); changes and current PA links are consolidated on the ODM prior authorization webpages.

Consult ODM consolidated PA links for current requirements: https://medicaid.ohio.gov/resources-for-providers/billing/prior-authorization-requirements/prior-authorizationrequirements.
ODM rule authority: Ohio Revised Code 5160.34 governs PA links and updates.

Prior Authorization

Obtain ODM prior authorization for ACT and include ANSA/SSDI documentation

ACT services require prior authorization from the ODM-designated entity before services may be rendered; PA requests must include ANSA results or documentation supporting a Social Security determination and the maximum PA period is twelve months.

Submit PA to the ODM designated entity and include ANSA results or Social Security documentation with the request.
Maximum prior authorization period for ACT is 12 months; teams must meet eligibility and fidelity review requirements before submitting PA.

Prior Authorization

PA required when peer support >4 hours and for OhioRISE respite

Prior authorization is required for peer support when services exceed four hours to the same individual on the same date; behavioral health respite for OhioRISE-enrolled youth also requires authorization by the OhioRISE plan consistent with ODM/OAC rules.

Peer support PA threshold: >4 hours per individual per date of service requires prior authorization.
OhioRISE behavioral health respite must be authorized by the OhioRISE plan per OAC rule 5160-59-03.1 and identified on the child and family-centered care plan.

Prior Authorization

PA required for specified codes and excess visits

Certain codes require prior authorization (for example 90899 and S8940) and payment for more than thirty acupuncture visits per benefit year requires prior authorization; payment for additional skilled therapy visits in non‑institutional settings can be requested through PA.

90899 (unlisted psychiatric service) and S8940 (equestrian/hippotherapy) require prior authorization.
Acupuncture (97810–97814): more than 30 visits per benefit year requires PA; some individual acupuncture codes are designated OPH services without PA up to threshold.
Additional skilled therapy visits (PT/OT/SLP) in non‑institutional settings can be requested via prior authorization.

Prior Authorization

Check ODM prior authorization links for current requirements

Providers must consult ODM consolidated prior authorization links for services requiring PA; Ohio Medicaid maintains and updates PA requirements on the Medicaid website.

Use ODM prior authorization webpages for current PA processes and any changes.
ODM authority: Ohio Revised Code 5160.34.

Prior Authorization

PA requirements governed by ORC 5160.34 — use ODM links

Ohio Revised Code 5160.34 governs prior authorization requirements and ODM's consolidated PA links; providers must follow those links for up‑to‑date PA rules for ODM‑ and MCO‑administered services.

ODM consolidates PA links per ORC 5160.34—consult those links for both fee‑for‑service and MCO‑administered PA changes.
PA processes may differ by service type; verify current instructions on the ODM site.

Prior Authorization

PA required for ASAM LOC2.5; notify for scheduled inpatient/ECT admissions

Prior authorization is required for ASAM LOC 2.5 (partial hospitalization) for SUD Day Treatment/IOP (minimum 20 hours/week); scheduled inpatient admissions (including those involving ECT) require notification at least five business days before admission.

LOC 2.5 requires PA and a minimum of 20 hours per week; if hours fall below 20 after the first four weeks, PA is rescinded and reimbursement may be at a lower LOC.
Scheduled inpatient admissions requiring PA/notification (including ECT inpatient admissions) must be notified at least 5 business days before admission; unscheduled admissions notified as soon as reasonably possible.

Prior Authorization

Inpatient admissions require PA/notification (scheduled >=5 business days)

Prior authorization or pre-service notification is required for inpatient admissions per plan rules; scheduled admissions must be notified at least five business days before admission and emergency admissions should be notified as soon as reasonably possible.

Failure to notify Optum of an inpatient admission involving ECT may result in reduced benefits per the member's benefit plan.
Check the member's benefit document for applicable penalties or grace periods regarding failure to notify.

Prior Authorization

PA required for psychophysiological therapy codes (90875, 90876)

Certain psychophysiological therapy codes (for example 90875 and 90876) require prior authorization; follow Ohio Medicaid PA links for current submission rules.

90875 and 90876 are PA‑required outpatient hospital services per the code table.
Confirm PA submission instructions on ODM consolidated PA pages.

Prior Authorization

OhioRISE behavioral health respite requires authorization

Behavioral health respite coverage for OhioRISE‑enrolled youth is subject to authorization by the OhioRISE plan in accordance with OAC rule 5160‑59‑03.1; PA must identify respite on the child and family‑centered care plan.

Respite must be authorized by OhioRISE and documented on the youth's child and family-centered care plan.
Amount, scope, and duration of respite are determined consistent with the youth's needs and OhioRISE authorization.

Prior Authorization

Follow ODM PA requirements and links (FFS and MCO services)

Providers must follow Ohio Department of Medicaid prior authorization requirements and links for both FFS and MCO‑administered services; ODM consolidates PA updates on its website.

ODM consolidated PA links: https://medicaid.ohio.gov/resources-for-providers/billing/prior-authorization-requirements/prior-authorizationrequirements
Verify whether the service is administered via ODM FFS or by an MCO and follow the appropriate PA route.

Prior Authorization

Check Ohio Medicaid consolidated PA links for current requirements

Consult Ohio Department of Medicaid prior authorization links maintained under ORC 5160.34 for current PA rules; providers are responsible for checking ODM resources prior to submission.

ODM maintains and updates PA requirements—providers must confirm current requirements via ODM links before submitting PA.
PA rules may change; use the consolidated ODM page to find service‑specific PA guidance.

Prior Authorization

PA required for excess psychological / neuropsych testing

Prior authorization is required when coverage limits for testing are exceeded—psychological testing beyond 12 hours/year or neuropsychological testing beyond 8 hours/year requires PA; testing past 20 hours/encounters per calendar year also triggers PA via the ODM authorization form.

Psychological testing limit: 12 hours per calendar year; Neuropsychological testing limit: 8 hours per calendar year—exceeding these limits requires PA.
Testing past 20 hours/encounters per calendar year requires PA submission through the Ohio Medicaid Authorization Form - Community Behavioral Health.

Note

Medication and program certification requirements

Medications listed in OAC appendices are covered when administered by eligible providers acting within their professional scope; opioid treatment services require OTP licensure and federal certification when applicable.

Medications in appendix to OAC rule 5160‑27‑03 are covered when rendered by eligible providers per rule 5160‑27‑01.
OTP medications require program licensure (Chapter 5122‑40) and, where applicable, SAMHSA federal certification (42 C.F.R. 8.11).

Step Therapy

Stepped‑care: use least‑restrictive, clinically appropriate services first

Provide treatment at the least restrictive, most clinically appropriate level first; consider less intensive alternatives (individual/family therapy, speech/OT, focused ABA) when higher‑intensity modalities are not indicated.

ABA should be provided at the least restrictive, most clinically appropriate level; if less intensive services are appropriate, consider alternatives such as speech, OT, psychotherapy, or focused ABA.
Justify higher intensity with baseline measurement and documented clinical need.

Step Therapy

Consider less intensive modalities when ABA intensity not indicated

When ABA intensity is not clinically indicated, consider stepping to less intensive modalities (e.g., focused ABA, speech therapy, occupational therapy, psychotherapy) and document rationale in the treatment plan.

Select focused versus comprehensive ABA based on severity and targeted goals; document why less intensive modalities are not adequate when requesting higher intensity.
Include caregiver training and generalization plans when transitioning services.

Step Therapy

Assess and modify treatment when progress inadequate or utilization low

If there is inadequate progress (for example no demonstrable progress within 6 months or utilization <80% of authorized hours), providers must assess barriers, document findings, and modify the treatment plan (increase time/frequency, change techniques, increase caregiver training, identify barriers and solutions).

Triggers for reassessment: no demonstrable progress within 6 months or utilization of PA period hours below 80% (or <80% over 2 weeks per CASP guidance).
Required documentation after inadequate progress: assessment of reasons, treatment modifications (time/frequency/technique), increased caregiver training, and plans to address barriers.

Billing Rule

Exclusive billing rules while enrolled on ACT — avoid duplicate billing

When a recipient is enrolled on an ACT team, no other Medicaid community behavioral health services are eligible for reimbursement except supported employment (if applicable), certain SUD services outside ASAM level one, and crisis services; ensure exclusive billing rules are followed to avoid denials.

ACT enrollment makes the ACT team the primary outpatient behavioral health provider and excludes billing of most other community behavioral health services.
Exceptions: supported employment per specialized recovery services, some SUD services outside ASAM level one, and crisis services by other providers.

Step Therapy

No explicit step therapy sequences specified

No formal step therapy sequences are specified in the document for most services; where stepwise care is discussed it emphasizes least‑restrictive care and clinical justification rather than mandated step sequences.

The policy does not establish specific step therapy sequences for CBTCBT, ECT, or other services; clinicians should follow clinical guidelines and member benefit terms.
Where 'step' considerations exist they focus on considering less intensive alternatives and documenting clinical rationale.

Note

Documentation Required

Use and repeat testing guidance — avoid unnecessary repeat testing

Repeat psychological/neuropsychological testing is not required for diagnosis or continued treatment and is considered medically unnecessary unless indicated by a change in clinical status; repeat testing may be performed only when clinically justified.

Repeat testing is only indicated for clinical changes or to inform treatment changes; routine repeat testing without indication is unnecessary.
Tele‑assessment exceptions and denial triggers are specified—ensure in‑person testing is unavailable or clinical justification for tele‑assessment exists.

Documentation Required

Maintain treatment records and current, credentialed treatment plans

Providers must maintain treatment records and progress notes per OAC rules 5160‑01‑27 and 5160‑8‑05; treatment plans must be current, developed by appropriately credentialed practitioners, and include measurable goals and required elements.

Treatment records must include treatment plans, progress notes, coordination documentation, provider credentials, dates of service, and caregiver training evidence.
Treatment plans for mental health and SUD must be developed by practitioners meeting OAC practitioner requirements.

Documentation Required

Document comprehensive diagnostic assessment demonstrating DSM‑5‑TR criteria

Diagnostic validation requires a comprehensive assessment completed by a licensed clinician demonstrating DSM‑5‑TR criteria, using standardized screening or diagnostic instruments (examples: ABC, CARS, M‑CHAT, ADI, ADOS), and including interviews, observations, record review, and formal examinations as appropriate.

ASD diagnosis must be validated by documented comprehensive diagnostic evaluation demonstrating DSM‑5‑TR criteria.
Use standardized instruments and multidisciplinary information to support the diagnosis and severity level.

Documentation Required

Include required documentation elements with authorizations and reviews

Authorization and concurrent‑review documentation must include types and number of therapies, behaviors targeted, progress toward measurable goals, discharge criteria, total days/week and hours/day requested, dates of service, provider credentials, and evidence of parent/caregiver training and participation.

PA and review packets should include updated treatment plans, progress data using the same measurement modes as baseline, and documentation of caregiver involvement.
Include measurable discharge criteria and plan for generalization/transition when applicable.

Documentation Required

Initial ABA assessment must include standardized functional assessments and baseline data

Initial ABA assessments must include standardized functional assessments, record review, baseline skill measurement, treatment goals, and functional behavioral assessments when maladaptive behaviors are present.

Assessment should determine baseline skills and inform measurable treatment goals and intensity.
Functional behavioral assessment (FBA) recommended when maladaptive behaviors occur; functional analysis if needed for safety‑risk behaviors.

Documentation Required

Maintain comprehensive ABA clinical documentation per member

Maintain a separate clinical record per member for ABA including autism diagnosis documentation, demographics, developmental and educational history, functional behavioral assessment, individualized treatment plan and revisions, daily progress notes (with place of service, start/stop times, provider, attendees, interventions, credentials), supervision documentation, and coordination with educational records when applicable.

Daily progress notes must document place of service, start/stop times, who rendered the service, interventions, attendees, and provider licensure/certification.
Include documentation of caregiver training, IEP/EI records if available, supervision records for behavior technicians, and credentials/certifications.

Documentation Required

Document ACT planned disenrollment with reasons, progress, linkage, and signatures

For planned ACT disenrollment, document reasons for disenrollment, progress toward goals, linkage and transfer of behavioral health care, and obtain signatures from the recipient/guardian, ACT team leader, and psychiatric prescriber.

Planned disenrollment documentation must include recipient and ACT team statements of reason, progress summaries, transfer arrangements, and required signatures.
Unplanned disenrollment scenarios (e.g., incarceration, hospitalization >2 months, inability to locate >45 days) also have documentation expectations for transition.

Documentation Required

Include ANSA/SSDI evidence and OAC‑compliant documentation with PA requests

Prior authorization requests and medical records for PA must include appropriate documentation such as ANSA results or documentation supporting Social Security determination; documentation must meet OAC rules 5160‑1‑27 and 5160‑8‑05.

Include ANSA results or supporting documents for SSI/SSDI eligibility when submitting PA for ACT.
Ensure PA documentation adheres to OAC documentation standards and contains required treatment plan and progress elements.

Documentation Required

ACT planned disenrollment requires detailed documentation and signatures

For planned ACT disenrollment, the ACT team must document reasons, progress toward goals, linkage to a new provider, and signatures of the recipient/guardian, ACT team leader, and psychiatric prescriber in the medical record.

Documentation must show active participation in disenrollment activities and transfer plans.
Maintain records in the recipient's medical file per OAC requirements.

Documentation Required

Document services within an individualized treatment plan; include OhioRISE respite on care plan

Document services as components of behavioral health treatment with goals/objectives in a current individualized treatment plan meeting rule 5122‑27‑03; OhioRISE respite must be identified on the child and family‑centered care plan and coordination with family/legal guardian must be documented.

All services must be documented with goals/objectives and integration into the individualized treatment plan.
OhioRISE respite must be included on the child and family‑centered care plan and documentation must show caregiver need for temporary relief.

Documentation Required

Retain clinical evaluation and treatment/maintenance plan for skilled therapy

Skilled therapy services require retention of the clinical evaluation and assessment and the treatment or maintenance plan in the provider's file; documentation must include diagnosis, current status, case history, test outcomes, prognosis, functional goals, dates of service, practitioner signature, and timelines for reevaluation.

Treatment/maintenance plan must specify amount, duration, frequency, methods, functional goals, and reevaluation timelines.
Evaluations should justify the provision of skilled therapy and include prognosis statements for expected improvement intervals.

Documentation Required

Document CBTCBT adjunctive use, clinical rationale, and qualified provider oversight

When requesting computer‑based CBT (CBTCBT) services, document that the service is adjunctive if applicable, provide clinical rationale referencing evidence limitations, and ensure services are provided by or under direction of a properly qualified behavioral health provider.

CBTCBT is considered unproven for outpatient SUD as a primary treatment—document adjunctive rationale when used as part of comprehensive care.
Verify the member's benefit document; benefit terms prevail and services must align with evidence‑based guidelines.

Documentation Required

Document medical necessity and staffing for mental health day treatment

Medical records for mental health day treatment must substantiate medical necessity and adhere to OAC documentation rules; programs must meet staffing and program day length requirements and maintain staff development plans.

Program day length: minimum 2 hours, maximum 7 hours per program day; document medical necessity in the patient's record.
Maintain staff development plans and evidence that plans are followed for program staff.

Documentation Required

Maintain CPST staff development, delegation agreements, and designated case coordinator

CPST providers must maintain evidence of staff development plans, document that plans are followed, and identify one CPST staff responsible for case coordination; delegated CPST services require written agreements and documentation.

Ensure a clear case coordinator employed by a certified agency; document delegation agreements for non‑certified entities.
Maintain staff development plans addressing systems of care, population characteristics, and CPST activities.

Prior Authorization

Adhere to PA and pre‑service notification timing (scheduled >=5 business days)

Follow prior authorization and pre‑service notification timing: scheduled inpatient admissions requiring PA/notification must be notified at least five (5) business days before admission; unscheduled/emergency admissions should be notified as soon as reasonably possible.

Failure to notify Optum of an inpatient admission involving ECT may result in benefit reduction—check the member's benefit plan for penalties.
Use ODM consolidated PA links to confirm notification submission processes.

Documentation Required

Document justification when MRSS response >60 minutes

If an initial MRSS mobile response occurs greater than 60 minutes from dispatch, the MRSS team must maintain documentation that supports the extended response time was appropriate.

Initial mobile response is expected within 60 minutes; if delayed, document justification for extended response time in the MRSS record.
MRSS de‑escalation up to 72 hours and stabilization up to 42 days must be documented per the individualized MRSS plan.

Documentation Required

OhioRISE enrollment starts on CANS submission; document respite on care plan

OhioRISE enrollment begins on the submission date of the CANS assessment; the child and family‑centered care plan must identify behavioral health respite and document provider awake requirements when applicable.

CANS assessment timeframes: assess within 72 hours and review within 10 business days per OhioRISE processes.
Respite must be identified on the child and family‑centered care plan and authorized by the OhioRISE plan.

Documentation Required

Document IHBT eligibility in ICR with CANS evidence and safety/transition plans

IHBT eligibility must be documented in the ICR including an Ohio‑specific CANS showing marked to severe impairment and justification that youth meet SED criteria, are under 21, and meet risk/placement criteria; document frequency of contacts, safety plans when indicated, and transition plans.

IHBT requires documentation of SED criteria, age <21, CANS marked to severe with impairment and actionable risk or placement risk.
ICR must document contact frequency, safety planning, family‑driven service planning, and transition to other services.

Documentation Required

Maintain written, signed prescriber orders in OTP records; review every 90 days

Opioid treatment program (OTP) records must include a written, signed, and dated prescriber's order for all medication administered, and the prescriber must be a staff or contract employee of the OTP; medication orders are valid for a maximum of 90 days and must be reviewed at least every 90 days.

Maintain prescriber's order in the patient record for all administered/dispensed medication; orders valid up to 90 days and require review every 90 days.
OTP prescribers must hold appropriate licensure and orders must comply with DEA and state pharmacy rules.

Documentation Required

Document temporary OTP transfers with consent, medication order, and receiving program acceptance

Temporary transfers of OTP patients require the patient's signed consent for disclosure, a medication change order permitting temporary services for up to 30 days, and evidence that the receiving program accepted responsibility; document all elements in the patient's record.

Temporary transfer documentation must include signed consent, medication change order (<=30 days), and documented acceptance by receiving program.
Chain of custody documentation required when transferring medication between programs.

Documentation Required

Document OTP take‑home orders, individualized rationale, and patient education (expire q90d)

Prescriber orders for OTP take‑home doses must be recorded and expire every 90 days; individualized rationale for take‑home authorization and education on safe storage/disposal must be documented in the clinical record.

Take‑home prescriber orders expire every 90 days; document individualized justification and patient education on safe storage/disposal.
During first 90 days of methadone treatment, take‑home limited to one dose per week; partial agonist take‑homes limited to 14 days for first 90 days.

Documentation Required

Individual plan of care must be written, comprehensive, and reviewed every 30 days

Individual plans of care (for inpatient/PRTF services) must be written, include diagnostic evaluation across medical/psychological/social/behavioral/developmental domains, state treatment objectives, prescribe integrated therapies, include post‑discharge coordination, and be reviewed every 30 days by the interdisciplinary team.

Develop the individual plan of care no later than 14 days after admission and review it every 30 days.
Ensure interdisciplinary team composition and plan elements align with OAC requirements for content and review intervals.

Documentation Required

Ensure provider licensure, Medicaid enrollment, and document qualifications for testing

Providers must be licensed and enrolled in Medicaid; psychologists or independent practitioners must be enrolled as eligible providers and maintain documentation of licensure and, for neuropsychological testing, evidence of training/expertise when required.

Licensed psychologists or independent practitioners must be enrolled in Medicaid to bill for testing services.
Automated testing and neuropsychological testing require appropriate licensure, certification, and documentation of training/expertise.

Denial Risk

Do not bill services that fail Ohio medical necessity criteria — denial risk

Services that do not meet Ohio's medical necessity definition (not clinically appropriate in type, frequency, extent, duration, or setting; not lowest cost effective alternative; or provided primarily for provider economic benefit or convenience) risk denial and should not be provided or billed.

Medical necessity requires consistency with accepted standards, clinical appropriateness, appropriateness to the condition, and being the lowest cost effective alternative (OAC rule 5160‑1‑01).
Services failing to meet these criteria are subject to denial and non‑payment.

Denial Risk

Do not bill explicitly non‑reimbursable services (education, room & board, habilitation, recreational, transport)

Claims for explicitly non‑reimbursable services (for example educational/vocational services, room and board, habilitation, recreational therapies, and transportation) will be denied; verify service coverage before billing.

Non‑covered examples: educational/vocational services, room & board, habilitation services, recreational/social activities (art, music, equine), and transportation.
Listing of a code in the policy does not imply coverage—confirm member benefit document and applicable laws before billing.

Prior Authorization

Failure to obtain PA for ABA (initial or concurrent) risks denial

Prior authorization is required for all covered ABA codes; failure to obtain PA for initial or concurrent ABA reviews risks denial of services or payment.

Submit PA with comprehensive assessment, treatment plan, and baseline measures to support clinical necessity.
Concurrent reviews must include updated progress data and treatment plan revisions.

Denial Risk

Continued treatment may be denied without documented progress or expectation of improvement

Continued‑treatment denials may be triggered by lack of documented reasonable expectation of clinically meaningful improvement, absence of documented progress toward defined goals, or treatment that makes symptoms persistently worse—document progress and expectation of improvement at each review.

Provide progress data for each targeted behavior using the same measurement modes as baseline and demonstrate reasonable expectation of continued clinically meaningful improvement.
If treatment makes symptoms worse or lacks progress, reassess and document treatment modifications.

Denial Risk

Inadequate progress (<6 months) or utilization <80% may prompt denial or discontinuation

No demonstrable progress within a 6‑month period or persistent utilization below 80% of authorized hours may prompt review and potential discontinuation; providers must document assessments and treatment changes addressing barriers when these thresholds are met.

Triggers: no demonstrable progress in 6 months; utilization of PA hours <80% (or <80% over 2 weeks per CASP guidance).
Documentation must include reasons for lack of progress and specific treatment modifications (increase time/frequency, change techniques, caregiver training, barrier solutions).

Denial Risk

Discharge risk when member no longer benefits — document transition and endpoints

Services may be discontinued when the member no longer benefits as demonstrated by lack of substantive progress toward goals across successive authorization periods; document discharge planning and measurable endpoints throughout treatment.

Discharge criteria should be documented at initiation and refined; demonstrate improvement from baseline or plateaued/no meaningful gains despite modifications.
When goals achieved, identify new goals or transition to less intensive interventions and document accordingly.

Prior Authorization

Obtain PA before delivering ACT services or risk denial

Prior authorization is required before rendering ACT services to avoid denial; submit PA with required documentation (ANSA or Social Security determination) to the ODM‑designated entity.

Do not provide ACT services prior to obtaining PA approval from the ODM designated entity.
Include required documentation and ensure the ACT team has met fidelity/eligibility criteria before PA submission.

Billing Rule

Adhere to ACT billing unit limits by provider category to avoid denial

Billing more ACT units than allowed per provider category or per recipient per month (up to four units total) or billing unauthorized service types may result in claim denial; follow per‑category unit limits and documentation requirements.

Billing limits per recipient per month: total up to 4 ACT units; medical prescriber max 1 unit; listed licensed clinicians max 1 unit; trainees/assistants/peers/QMHS up to 2 units.
Ensure medical prescriber has at least one contact every three months and maintain required documentation for each billed unit.

Denial Risk

Avoid peer support denial triggers: PA, duplication, ratio, and concurrent intensive services

Peer support services risk denial or non‑payment when provided without required prior authorization (if >4 hours to same individual on same date), when duplicative of other reimbursable services, when group ratio exceeds 1:12 certified peer supporter:client, or when provided concurrently with specified intensive services.

PA required if peer support >4 hours per individual per date of service.
Peer support is not reimbursable when recipient is receiving IHBT, ACT, MRSS, SUD residential, inpatient psychiatric, or PRTF services except to support admission/discharge.
Do not bill peer support in group settings exceeding 1:12 certified peer supporter:client ratio.

Denial Risk

Risk of denial for non‑treatment or non‑covered services (recreational, unlicensed, educational)

Services unrelated to treatment of a specific behavioral health diagnosis (for example recreational therapy, activities primarily for social interaction, or services by unlicensed individuals except supervised trainees) may be denied as not medically necessary under OAC rules.

Examples of non‑treatment services that may be denied: recreational therapies (art, music, equine), encounter groups, workshops, sensitivity training, and activities primarily for social interaction.
Ensure services are tied to the individual's treatment plan and diagnosis to avoid denial.

Denial Risk

CBTCBT is not medically necessary as primary outpatient SUD treatment — denial risk

Computer‑based CBT (CBTCBT) is considered unproven and not medically necessary as outpatient therapy to treat substance use disorders when used as primary outpatient treatment; requests for CBTCBT may be denied unless documented as adjunctive with clinical rationale and qualified oversight.

CBTCBT (e.g., reSET®, reSET‑O®) should be used adjunctively under clinician supervision and is not supported as standalone outpatient SUD treatment.
Document clinical justification, evidence limitations, and supervision when requesting CBTCBT services.

Denial Risk

Failure to follow ODM PA processes (e.g., excess skilled therapy or acupuncture) risks denial

Follow Ohio Medicaid prior authorization processes for services that require PA (for example additional skilled therapy visits or more than 30 acupuncture visits); failure to follow PA process may result in denial.

Confirm PA requirements and submission instructions on ODM consolidated PA webpages.
Services exceeding stated thresholds (e.g., >30 acupuncture visits, excess skilled therapy visits) require PA per OAC rules.

Denial Risk

Notify Optum for scheduled inpatient admissions (ECT) or risk benefit reduction

Failure to notify Optum of an inpatient admission that includes ECT may result in reduced benefits per the member's benefit plan; scheduled inpatient admissions requiring notification must be reported at least five business days before admission.

Notify Optum per plan rules; failure to notify may reduce member benefits—check member's benefit document for penalties.
Scheduled inpatient admissions requiring notification: at least 5 business days prior to admission.

Billing Rule

Code listing is not coverage — verify member benefit document

Inclusion of a billing code in the policy does not imply that the service described by that code is covered; benefit coverage is determined by the member‑specific benefit plan and applicable laws—verify member benefits before billing.

The policy's code lists are for reference—coverage and reimbursement depend on the member's benefit document and applicable laws.
Always check member‑specific benefit details prior to billing for services whose inclusion in the policy is not a coverage guarantee.

Denial Risk

Respite limited to OhioRISE enrollees in qualifying settings — authorization required

Behavioral health respite reimbursement is limited to youth enrolled in OhioRISE and only in qualifying residential settings (primary caregiver's home not owned/leased by a provider, ODJFS‑licensed foster home, kin home, or medically fragile/treatment foster home); respite must be authorized by OhioRISE and meet plan criteria.

Respite reimbursement allowed only when youth is enrolled in OhioRISE and resides in qualifying settings as specified in OAC rules.
Respite cannot duplicate other foster home respite reimbursement or be used to cover room and board costs.

Documentation Required

Maintain signed prescriber orders in OTP records to avoid denial

Failure to maintain a written, signed, and dated prescriber's order in the patient record for all medications administered, personally furnished, or dispensed in an OTP may risk denial or payment issues; ensure prescriber orders are current and retained.

Prescriber's orders must be kept in the patient record and reviewed at least every 90 days.
Ensure prescriber is staff or contract employee of the OTP and orders comply with DEA/state pharmacy rules.

Denial Risk

Tele‑assessment denial triggers — ensure eligibility, licensure, platform, materials, and consent

Tele‑assessment is not covered when in‑person testing is available, the provider is not proficient or not licensed in the state where the member receives testing, HIPAA‑compliant platforms or secure test materials are not used, adequate audio‑visual monitoring cannot occur, the member is not a candidate for remote testing, or informed consent for telehealth testing has not been obtained.

Do not perform tele‑assessments unless in‑person testing is unavailable or there is clear clinical justification and tele‑assessment integrity can be maintained.
Use HIPAA‑compliant platforms and secure test materials, confirm provider licensure in member's state, and obtain informed consent for telehealth testing.

Note

Codes, Fee Schedules, and Visit Limits

Referenced rule-based code lists and appendicesmixed

No codes listed

Notesmixed

See ODM links

Refer to Ohio Department of Medicaid consolidated prior authorization and fee schedule links (OAC rule 5160.34) for rule-based code lists and appendices.

Coding and fee schedulesmixed

See ODM links

CPT, HCPCS, EAPG, and non-institutional codes per Ohio Medicaid fee schedules and prior authorization pages (see https://medicaid.ohio.gov/resources-for-providers/billing/fee-schedule-and-rates/schedules-and-rates and prior authorization links).

External fee schedule linksmixed

No codes listed

Diagnosis Codes (listed)ICD-10

F84.0

Autistic Disorder

Notesmixed

Reference

Listing of a code does not imply coverage; benefit coverage determined by member-specific plan and applicable laws.

Coding and fee schedule referencesmixed

https://medicaid.ohio.gov/resources-for-providers/billing/prior-authorization-requirements/prior-authorizationrequirements	ODM consolidated prior authorization requirements (OAC 5160.34).
https://medicaid.ohio.gov/resources-for-providers/billing/fee-schedule-and-rates/schedules-and-rates	ODM fee schedules and rates (CPT/HCPCS/EAPG/Non-institutional codes).
https://medicaid.ohio.gov/resources-for-providers/billing/billing	ODM billing resources and fee schedule references.

Notesmixed

No codes listed

Applicable procedure codes listedCPT

97810	Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
97811	Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needles(s).
97813	Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
97814	Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needles(s).
90899	Unlisted psychiatric service or procedure.
S8940	Equestrian/hippotherapy, per session.

Applicable PDCT HCPCSHCPCS

A9291

Prescription digital cognitive and/or behavioral therapy, FDA-cleared, per course of treatment

Relevant ICD-10 codes for substance use disordersICD-10

F10.10	Alcohol abuse, uncomplicated
F10.20	Alcohol dependence, uncomplicated
F11.1 - F11.9	Opioid abuse and dependence
F12.10	Cannabis abuse, uncomplicated
F12.20	Cannabis dependence, uncomplicated
F14.10	Cocaine abuse, uncomplicated
F14.20	Cocaine dependence, uncomplicated
F15.10	Other stimulant abuse, uncomplicated
F15.20	Other stimulant dependence, uncomplicated
F19.10	Other psychoactive substance abuse, uncomplicated

1–10 of 11

1/2

Applicable PDCT HCPCSHCPCS

A9291

Prescription digital cognitive and/or behavioral therapy, FDA-cleared, per course of treatment

Relevant ICD-10 codes for substance use disordersICD-10

F10.10	Alcohol abuse, uncomplicated
F10.20	Alcohol dependence, uncomplicated
F11.1 - F11.9	Opioid abuse and dependence
F12.10	Cannabis abuse, uncomplicated
F12.20	Cannabis dependence, uncomplicated
F14.10	Cocaine abuse, uncomplicated
F14.20	Cocaine dependence, uncomplicated
F15.10	Other stimulant abuse, uncomplicated
F15.20	Other stimulant dependence, uncomplicated
F19.10	Other psychoactive substance abuse, uncomplicated

1–10 of 11

1/2

Applicable Codes and notesCPT | mixed

90875	Psychophysiological Therapy
90876	Psychophysiological Therapy
90911	Biofeedback/peri/uro/rectal (90911 listed; 90912/90913 noted as discontinued/non-covered).
90912	90912 (discontinued/non-covered as noted)
90913	90913 (discontinued/non-covered as noted)

Prior authorization notesmixed

90875	PA required (OPH service).
90876	PA required (OPH service).
90899	Prior authorization required for 90899 (unlisted psychiatric service).
S8940	Prior authorization required for S8940 (equine/hippotherapy).

Codes referenced for testing and related servicesCPT

96105	Assessment of Aphasia (speech/language evaluation) — not considered psychological testing; often done by speech-language therapist
96125	Standardized cognitive performance testing (occupational therapy assessment) — not considered psychological/neuropsychological testing
96110	Developmental testing (example code) — adjunct to developmental surveillance
96112	Developmental testing (example code)
96113	Developmental testing (example code)
96127	Brief emotional/behavioral assessment (screening) — not considered psychological testing for definitive diagnostic decisions

Notesmixed

No codes listed

Service frequency limits referenced

SBIRT frequency1 per code per billing provider per calendar year

Psychiatric diagnostic evaluation1 encounter per recipient per billing provider per calendar year

SUD assessment2 assessments per recipient per billing agency per calendar year

SUD urine drug screen1 urine drug screen per day per recipient

Peer recovery support4 hours per day per recipient

Supervision proportion

Minimum supervision proportionMinimum 5% of direct hours should be supervised

Supervision contextSupervision is proportional to treatment dosage and separate from treatment hours

ApplicationApplies to ABA technicians and treatment delivery per policy supervision standards

Caregiver involvement

Caregiver training requirementCaregivers are required to complete training and be involved at minimum weekly, ideally minimally 2 hours per month

Caregiver engagement elementsOngoing training in ABA principles; participation in sessions and understanding progress

Barrier managementIf barriers prevent caregiver participation, providers must address barriers individually

Utilization attention threshold

Utilization attention thresholdPrior authorization period hours below 80% requires attention during concurrent review

Short-term utilization flagPer CASP, utilization below 80% over a 2-week period requires attention

Action requiredConcurrent review should address barriers to utilizing authorized hours and document solutions

Prior authorization period for ACT

ACT prior authorization period12 months

PA submission requirementRequest PA from the ODM designated entity and include ANSA or SSDI/SSI documentation

Maximum PA interval contextMaximum amount of ACT service which may be prior authorized at any one time is twelve months

Fidelity review interval

Fidelity review intervalEvery 12 months (DACTS fidelity review)

Year-one requirementIn year one an ACT team must complete a DACTS fidelity review by an independent validation entity

Documentation needTeams must have documented evidence of compliance prior to submitting PA requests

Prior authorization threshold

Peer support PA thresholdPrior authorization required when more than 4 hours are provided to the same individual on the same date

ContextApplies to peer recovery support services per Ohio rules; transportation-only activities not covered

DocumentationPA requirements and changes available via ODM prior authorization links

Group ratio limit

Group ratio limitMaximum 1 certified peer supporter to 12 clients in group setting

Reimbursement constraintPayment not allowable when certified peer supporter to client ratio exceeds 1:12

ApplicabilityApplies to peer support services delivered in group settings per rule 5122-29-15

Acupuncture visit prior authorization threshold

Acupuncture PA thresholdMore than 30 visits per benefit year requires prior authorization

Covered conditions noteAcupuncture is covered only for specified conditions per OAC rule 5160-8-51; PA required beyond threshold

ODM PA linkPA processes governed by Ohio Revised Code 5160.34 and ODM consolidated PA links

reSET duration

reSET duration12 weeks (reSET® PDCT course)

Intended usereSET® is FDA-cleared and intended to be used in conjunction with standard outpatient treatment, not as a standalone

reSET-O contextreSET-O® intended as adjunct to outpatient OUD treatment combined with buprenorphine and contingency management

Program day length

Program day length minimumMinimum 2 hours per program day

Program day length maximumMaximum 7 hours per program day

DefinitionA 'program day' is the total hours an individual receives mental health day treatment during a 24-hour calendar day

LOC 2.5 prior authorization threshold

LOC 2.5 PA thresholdLOC 2.5 (partial hospitalization) requires minimum 20 hours/week for prior authorization

Rescission ruleIf after first 4 consecutive weeks services are <20 hours/week, PA is rescinded and services reimbursed at lower LOC not to exceed 19.9 hours/week

ASAM basisDay Treatment/IOP services follow ASAM treatment criteria for levels of care

IMD age and length limits

IMD admission age rangeAdmission age 21–64 years

IMD monthly length limitLimit 15 days per month when billed under 42 CFR 438.6(e)

Regulatory contextApplies to IMD settings providing inpatient psychiatric or SUD treatment per federal rule

De-escalation period

De-escalation periodDe-escalation services provided up to 72 hours

Activities includedUrgent assessment, initial safety plan, crisis intervention, telephonic psychiatric consultation as needed

MRSS contextApplies to MRSS mobile response de-escalation phase per rule 5122-29-14

Stabilization period

Stabilization periodUp to 42 days of stabilization per individualized MRSS plan

Service scopeContinued monitoring, coordination, skill-building and linkage to supports during stabilization

Eligibility age noteMRSS serves youth up to age 21 and offers up to 42 days of services

Age limit for IHBT

IHBT age limitUnder twenty-one years of age

Eligibility basisMust meet SED criteria with Ohio-specific CANS indicating marked to severe impairment

DocumentationIHBT eligibility documented by IHBT team in the ICR including CANS and justification

Prescriber order review interval

Prescriber order review intervalPrescriber's order valid for maximum 90 days and must be reviewed at least every 90 days

Take-home ordersOrders for take-home doses also expire every 90 days and require individualized rationale and documentation

Record requirementWritten, signed, and dated prescriber's order must be maintained in patient record

Psychological testing annual hours

Psychological testing annual limitMaximum 12 hours per recipient per calendar year

PA for excessLimit may be exceeded only with prior authorization from the ODM designated entity

EPSDT noteTesting may be covered under EPSDT/Healthchek with different considerations

Neuropsychological testing annual hours

Neuropsychological testing annual limitMaximum 8 hours per recipient per calendar year

PA for excessLimit may be exceeded only with prior authorization from the ODM designated entity

Coverage exclusionsCertain neuropsych testing indications (e.g., baseline sport-related concussion in asymptomatic persons) noted as not medically necessary

Prior authorization trigger for testing

Testing prior authorization triggerTesting past 20 hours/encounters per calendar year requires prior authorization (Ohio Medicaid Authorization Form - Community Behavioral Health)

Annual aggregate limitsPsychological testing max 12 hours/year; neuropsychological testing max 8 hours/year; PA required beyond those limits

Documentation requirementPA requests must include clinical justification and testing details per ODM guidance

Key Terms and Service Definitions

Medical necessity definition per Ohio Medicaid

Ohio Medicaid medical necessity definitionMeets generally accepted standards of medical practice; clinically appropriate in type, frequency, extent, duration, and setting; appropriate to the condition and expected to produce desired outcome; lowest cost effective alternative; provides unique diagnostic information when applicable; not primarily for provider economic benefit

ApplicabilityDefinition applies across Medicaid program; additional specific criteria may be set forth in ODM coverage policies or rules

ReferenceSee OAC rule 5160-1-01 for additional information

ABA definition — Applied Behavior Analysis

ABA definitionApplied Behavior Analysis (ABA) is a scientific discipline that analyzes, designs, implements, and evaluates environmental modifications to produce meaningful changes in human behavior; leading evidence-based treatment for ASD

RecognitionABA is the standard of care for treating ASD and supported by major professional organizations

ScopeEffective across the lifespan and for a variety of disorders and conditions per CASP

ASD (DSM-5-TR criteria)

ASD diagnostic elements (DSM-5-TR)Persistent deficits in social communication/interaction and restricted, repetitive patterns of behavior, with symptoms causing clinically significant impairment; diagnosis requires validation by comprehensive assessment demonstrating DSM-5-TR criteria

Diagnostic componentsAssessment should include interviews, direct observation, record review, language/cognitive/adaptive examinations, and standardized screening/diagnostic tools

Screening agesScreening recommended at 18- and 24-month well-child visits

Standard diagnostic and screening instruments (examples)

Examples of diagnostic/screening instrumentsABC, CARS/CARS-2, CHAT/M-CHAT, CSBS-DP-ITChecklist, ADI, ADOS/ADOS-2, DISCO, SCQ, SRS

Use guidanceAt least one validated measure should be used at baseline and repeated at least twice annually when appropriate

RoleTools inform but do not replace multidisciplinary clinical diagnosis

ASD Severity Levels (DSM-5-TR)

ASD Severity Levels (DSM-5-TR)Levels 1–3 describing required support: Level 1 (requiring support), Level 2 (requiring substantial support), Level 3 (requiring very substantial support)

Functional implicationsSeverity levels describe social communication deficits and restricted/repetitive behaviors impacting function and required supports

AssessmentSeverity assigned based on clinical assessment across contexts

ACT definition — Assertive Community Treatment

ACT definitionAssertive Community Treatment (ACT) is a multidisciplinary, team-based intensive community behavioral health service available 24/7 for adults with severe and persistent mental illness

Team roleACT team is the sole outpatient behavioral health provider for ACT recipients and provides comprehensive services including psychiatry, care coordination, crisis intervention, and supports for housing and employment

AvailabilityServices available twenty-four hours a day, seven days a week

ANSA score requirement

ANSA score requirementEligibility may be based on ANSA: score of 2 or greater on at least one 'mental health needs' or 'risk behaviors' item, or a score of 3 on a 'life domain function' item

AdministrationANSA must be administered by an individual with a bachelor's degree or higher and training in the assessment

Use in PAANSA results included with prior authorization requests for ACT services

Fidelity review (DACTS)

Fidelity review (DACTS)Teams must complete a DACTS fidelity review in year one and every 12 months thereafter by an independent validation entity recognized by ODM

Documentation requirementEvidence of compliance with fidelity requirements must be available prior to PA requests

ResourceDACTS fidelity scale and protocol referenced on Medicaid site

Peer support services definition

Peer support services definitionActivities promoting resiliency, recovery, self-determination, advocacy, well-being and skill development through peer relationships; individualized and trauma-informed

Settings and recipientsProvided to individuals, families, or groups and may include caregivers when addressing individual's treatment plan goals

LimitationsPrior authorization required if >4 hours to same individual on same date; group ratio max 1:12

Behavioral Health Respite Care definition

Behavioral health respite definitionTemporary direct care and supervision to provide relief to families/caregivers of a member (particularly youth) with serious emotional disturbance

AuthorizationOhioRISE behavioral health respite requires authorization by the OhioRISE plan and is identified on the child and family-centered care plan

Settings and activitiesCan be in-home or in specified community settings; includes normal activities of daily living and transportation as part of service

Acupuncture definition and context

Acupuncture definitionProcedures involving stimulation of body points, commonly via needle penetration with manual or electrical manipulation; studied for pain and some behavioral health conditions

Coverage contextAcupuncture is a covered benefit for specified conditions under OAC rule 5160-8-51; payment for >30 visits per benefit year requires PA

Evidence noteResearch has been conducted on behavioral health uses, but many complementary modalities considered unproven for BH/SUD indications

Dance/Movement Therapy (DMT) definition

Dance/Movement Therapy (DMT)Psychotherapeutic use of movement to promote emotional, cognitive, physical, and social integration delivered by trained therapists

ScopeInterventions use affective, behavioral, motoric, cognitive and systemic strategies; provided by appropriately trained professionals

Evidence stanceListed among complementary modalities with limited evidence for BH/SUD treatment in policy context

Music Therapy definition

Music Therapy definitionClinical use of music interventions by trained therapists to achieve individualized therapeutic goals

ApplicationTherapists assess emotional wellbeing and social functioning and design sessions based on client needs

Policy noteListed among complementary modalities and considered unproven for some BH/SUD indications

Computer-based treatment CBT (CBTCBT) definition

CBTCBT definitionComputer-based delivery of cognitive behavioral therapy via computer, internet, or mobile device for outpatient SUD treatment

reSET examplereSET® is a 12-week FDA-cleared PDCT for stimulants, cannabis, cocaine, and alcohol intended to be used with standard outpatient treatment, not standalone

reSET-O examplereSET-O® intended as adjunct to outpatient OUD treatment combined with buprenorphine and contingency management

reSET® / reSET‑O® PDCT description

reSET / reSET-O PDCT descriptionFDA-cleared prescription digital therapeutics: reSET® is 12-week PDCT for certain SUDs; reSET-O® used adjunctively with buprenorphine for OUD

Intended useBoth intended as adjuncts to clinician-led outpatient treatment, not stand-alone interventions

Coverage notePolicy notes reSET is not intended as stand-alone or for opioid dependence

Community Psychiatric Supportive Treatment (CPST) definition

CPST definitionCommunity-based, mobile or multidisciplinary services addressing individualized mental health needs to improve community functioning and independence

Typical activitiesOngoing assessment, daily living skills, ISP coordination, symptom monitoring, crisis management, advocacy, skill-building and linkage to supports

DocumentationServices must be identified in an ISP and provided by qualified staff per OAC rules

Program day definition for mental health day treatment

Program day definitionA program day is the total amount of hours an individual receives mental health day treatment service during a 24‑hour calendar day

Program day lengthMinimum of 2 hours and up to 7 hours of scheduled intensive activities per program day

PurposeIntensive, structured, goal‑oriented services to stabilize or improve functioning and move to least restrictive care

ECT definition

ECT definitionTreatment applying a brief intense electrical current to precise head locations to induce a seizure <1 minute, administered by privileged psychiatrist with anesthesia support

IndicationsMedically necessary for severe, treatment‑resistant depression and select bipolar disorder or schizophrenia not responsive to other treatments

Notification requirementScheduled inpatient admissions requiring PA/notification must be notified at least 5 business days before admission

IMD definition

IMD definitionInstitution for Mental Disease (IMD): facility of >16 beds primarily providing diagnosis, treatment, or care of persons with mental diseases

ScopeIMD status applies regardless of licensing if facility operated primarily for mental disease care

Exclusions noteSpecial Federal rules and waivers affect coverage for IMD services (see CFR references)

Mobile Response and Stabilization Service (MRSS) definition

MRSS definitionMobile Response and Stabilization Service (MRSS) is a mobile team intervention for youth up to age 21 providing rapid response, de-escalation up to 72 hours, and up to 42 days of stabilization and linkage to supports

Response timeInitial mobile response within 60 minutes of call; MRSS offers up to 42 days stabilization

ActivitiesSafety assessment, crisis de-escalation, initial safety plan, CANS administration, stabilization planning and linkage

Neurofeedback/Biofeedback definition

Neurofeedback/Biofeedback definitionNon-invasive technique using real-time physiologic monitors to provide feedback enabling self-regulation of physiologic functions and mental states

Evidence summaryReviewed evidence does not clearly demonstrate treatment effect for behavioral or substance use disorders; studies have limitations

Coverage implicationPolicy implies limited or no coverage as not sufficiently evidence-based for BH/SUD indications

Behavioral health respite definition (OhioRISE)

Behavioral health respite (OhioRISE) definitionShort-term temporary relief to the primary caregiver of an OhioRISE-enrolled youth to support and preserve caregiving relationship

AuthorizationRespite services subject to OhioRISE plan authorization per OAC rule; amount/scope/duration determined by OhioRISE plan

SettingsProvided in eligible home or community settings (not provider-owned/leased caregiver home; licensed foster home; crisis house; etc.)

CANS definition and role

CANS roleChild and Adolescent Needs and Strengths (CANS) assessment used to determine OhioRISE eligibility and to gather info about child/youth and family strengths and needs

TimelinesReferral to CANS assessors within 1 business day; assessment within 72 hours; assessment reviewed within 10 business days; enrollment begins on CANS submission date

AssessorsCANS administered by qualified assessors per OhioRISE protocols

Opioid Treatment Program (OTP) definition

OTP definitionOpioid Treatment Program (OTP): community addiction services provider offering supervised assessment and medication-assisted treatment for opioid use disorder

Medication administration rulesMethadone administered orally as liquid; prescriber's order valid max 90 days and reviewed every 90 days; programs open at least six days/week

Take-home rulesFirst 90 days methadone take-home limited to single dose/week; partial agonist first 90 days limited to 14-day supply; interim maintenance and other safeguards apply

Serious emotional disturbance (SED) definition

SED definitionSerious emotional disturbance (SED) as defined in OAC rule 5122-2401 applied for IHBT admission determinations

UseIHBT eligibility requires clinical determination of SED per rule and documentation in ICR

Age linkageSED criteria applied for youth under 21 for IHBT services

Individual plan of care definition

Individual plan of care definitionA written plan developed for each beneficiary to improve condition so inpatient care is no longer necessary

Timing and reviewPlan must be developed and implemented no later than 14 days after admission and reviewed every 30 days

ContentMust include diagnostic evaluation across domains, treatment objectives, integrated therapies, and post-discharge coordination

Psychological/Neuropsychological/Automated testing definitions

Psychological Test Evaluation Services definitionFormal procedures using validated tests to measure intellectual, cognitive, emotional, behavioral functioning and to identify psychopathology and adaptive skills

Neuropsychological Test Evaluation definitionFormal procedures focused on identifying brain injury/dysfunction and associated functional deficits

Automated Testing definitionAutomated single‑instrument administration, scoring and interpretation used for screening or tracking changes; provider must meet licensure/training requirements

Enumerated Treatment Modalities and Specific Criteria

Visit, Unit, and Frequency Limits

SBIRT and related visit limits

SBIRT visit limit1 per code per billing provider per calendar year

Psychiatric diagnostic evaluation limit1 encounter per recipient per billing provider per calendar year

SUD assessment limit2 assessments per recipient per billing agency per calendar year

SUD urine drug screen limit1 per day per recipient

Peer recovery support limit4 hours per day per recipient

Psychiatric diagnostic evaluation

Psychiatric diagnostic evaluation1 encounter per recipient per billing provider per calendar year

ContextMay be with or without medical services as specified in policy

PA noteLimits can be exceeded with prior authorization per ODM links

Substance use disorder assessment limit

Substance use disorder assessment2 assessments per recipient per billing agency per calendar year

Rule referenceAs referenced in OAC rule 5160-27-09

PA possibilityLimits may be exceeded with prior authorization

SUD urine drug screening limit

SUD urine drug screen limit1 urine drug screen per day per recipient

Rule referencePer OAC rule 5160-27-09

Billing contextDaily limit applies regardless of setting unless PA indicates otherwise

Peer recovery support limits

Peer recovery support per-day limit4 hours per day per recipient

PA triggerPrior authorization required if provided for more than 4 hours to same individual on same date

Group and duplication limitsNot reimbursable when duplicative of other Medicaid services; group ratio capped at 1:12

Documentation on hours vs outcomes

Hours vs outcomes noteNo clear evidence correlating higher weekly ABA hours with better outcomes; some studies show no difference between 15 vs 25 hours/week; individual justification required for requested hours

Treatment planning implicationIntensity should be justified by baseline measures and individualized clinical need

Caregiver considerationConsider developmental needs, rest breaks, and family time when planning intensity

ACT availability and units

ACT availability24/7 availability

PA maximum periodPrior authorization period for ACT may be up to 12 months

Units billableProvider may bill up to 4 ACT units per recipient per month when requirements met

ACT units and unit allocations

ACT unit - prescriber1 unit per recipient per month for services by ACT team medical prescriber

ACT unit - licensed clinicians1 unit per recipient per month per listed licensed clinician roles

ACT unit - trainees/peersUp to 2 units per recipient per month for trainees/assistants/peers/QMHS

Unit for services by medical prescriber

Unit for medical prescriber services1

ContextApplies to ACT team medical prescriber billing limits per recipient per month

RequirementPrescriber must have at least one contact every three months

Unit for services by listed licensed clinicians

Unit for listed licensed clinicians1

ExamplesPsychologist, LISW, LPCC, etc., subject to per-recipient per-month limits

Billing noteUnits billable only when clinical and billing requirements for each unit are met

Units for trainees/assistants/peers/QMHS

Units for trainees/assistants/peers/QMHS2 units per recipient per month

Roles includedPsychology assistant, trainee, social worker trainee, QMHS, peer recovery supporter, etc.

Billing conditionSubject to overall ACT unit monthly cap of up to 4 units per recipient

Peer support prior authorization and limits

Peer support PA rulePrior authorization required if peer support >4 hours to same individual on same date

Group ratioGroup ratio must not exceed 1 certified peer supporter to 12 clients

Non-coverage contextsPeer support not reimbursable when duplicative of other Medicaid services or when member receiving certain intensive services

Acupuncture visits before prior authorization required

Acupuncture visits before PA30 visits per benefit year before prior authorization required

PA threshold restatementPayment for more than 30 acupuncture visits per benefit year requires prior authorization

Rule referenceSee OAC rule 5160-8-51 and ODM PA links

Day Treatment / IOP visit limits

Day Treatment / IOP weekly limitsAdults <9 hours/week for LOC1; Adolescents <6 hours/week for LOC1; LOC2.5 requires >=20 hours/week for PA

LOC2.5 PA rescissionIf after first 4 consecutive weeks services <20 hours/week, prior authorization is rescinded and reimbursement at lower LOC not to exceed 19.9 hours/week

ASAM basisServices defined by ASAM criteria for admission, continued stay, and discharge

MRSS visit limits and timelines

MRSS stabilization maxUp to 42 days stabilization per individualized MRSS plan

MRSS de-escalation maxDe-escalation services up to 72 hours

Response expectationInitial mobile response typically within 60 minutes of contact

Behavioral health respite authorization scope

Behavioral health respite authorizationAmount, scope, and duration determined by OhioRISE plan authorization per rule 5160-59-03.1

Enrollment requirementRespite reimbursable only for youth enrolled in OhioRISE and residing in qualifying settings

Plan inclusionRespite must be identified on the child and family-centered care plan

Psychological and Neuropsychological testing limits

Psychological testing annual limit12 hours per recipient per calendar year (may be exceeded with prior authorization)

Neuropsychological testing annual limit8 hours per recipient per calendar year (may be exceeded with prior authorization)

PA threshold for testingPsychological/Neuropsych testing requires PA past 20 hours/encounters per calendar year

Background and Policy Scope

Background: Ohio Medicaid defines medical necessity standards that govern coverage decisions. Services must be consistent with accepted medical practice and be clinically appropriate in type, frequency, duration, and setting; they must be appropriate to the member's condition, represent the least costly effective alternative, provide unique diagnostic information when applicable, and not be primarily for the economic benefit or convenience of the provider. EPSDT (Healthchek) requirements apply for members under age 21 and may broaden coverage for eligible children and youth.

Medicaid reimbursement does not cover room and board costs under behavioral health services, and federal Title IV‑E funding must not be used to cover OhioRISE behavioral health respite where that would duplicate excluded room/board costs. OhioRISE behavioral health respite itself is subject to plan authorization and is reimbursable only under the specific location, enrollment, and funding rules established by the OhioRISE plan and Ohio Administrative Code.

Policy Revision History

2019-05-20revision

Version 1 published (initial revision entry recorded).

2020-01-31revision

Version 2 published (document update recorded).

2021-04-19revision

Version 4 published (annual update).

2022-10-19revision

Version 5 published (document update).

2023-01-01revision

Annual review performed (2023-01-01).

2023-12-12revision

Interim update — updated weblinks, clarified references to Ohio Administrative Code and Ohio Revised Code, removed outdated language, and formatting updates.

2024-07-01revision

Annual review and integration of Optum Behavioral Clinical Policies and Optum Supplemental Clinical Criteria with updates per OAC and ORC; CQOC approval 2024-02-20 and ODM approval 2024-05-02 noted.

2025-08-01effective_dateLatest

Policy effective date updated to 2025-08-01 following annual review and multiple content updates including CAM, CBT4CBT for SUD, Neurofeedback, TMS, Wilderness Therapy, and updates to ABA, ECT, and Psychological/Neuropsychological Testing; CQOC approvals 03/18/2025 and 06/17/2025 and ODM approval 06/27/2025 recorded.