Ohio has robust Medicaid coverage for addiction treatment services and plentiful online resources for behavioral health providers interested in serving Medicaid patients. Most of the requirements and restrictions Ohio places on addiction treatment for Medicaid patients are common sense rules that are fully informed by ASAM standards of care. Still, learning the ins and outs of Medicaid billing in Ohio comes with its own challenges.

In this post, we’ll answer some of the most common questions we hear from addiction treatment providers who are new to billing Medicaid in Ohio.  

What addiction treatment services require prior authorization for Medicaid patients in Ohio? 

Ohio’s Behavioral Health Provider Manual details all of the prior authorization requirements for addiction treatment services. For Ohio Medicaid patients, the following addiction treatment services require prior authorization: 

• More than 4 Hours of SUD Peer Recovery Services Per Day, billed under CPT code H0038. These are capped at 4 hours per day, additional hours require prior authorization. 

• SUD Residential Services, billed under H2034, H2036. Residential treatment does not require prior authorization for the first 30 days. Any stay over 30 days requires prior authorization. Patients are allowed to have two 30-day-long residential stays per calendar year without triggering any prior authorization requirements. After the first two stays, any additional stays require immediate prior authorization.  

• MRSS Stabilization Services, billed under CPT code S9482.

• More than 2 Alcohol or Drug Assessments in a single year, billed under CPT code H0001. These are capped at 2 assessments per person per year.

• More than 1 TBS Group Per Diem, CPT code H2020. These are capped at 1 service per client, per day. 

• Assertive Community Treatment, also referred to as ACT, billed under CPT code H0040.

• Intensive Home Based Treatment, also known as IHBT, billed under CPT code H2015. 

• Partial Hospitalization, billed under H0015 - for both adults and adolescents 

• More than One Psychiatric Diagnostic Evaluation in a Single Year  - these are limited to one encounter per person, per year without prior authorization. Additional evals require prior authorization. These are billed under CPT codes 90791 and 90792.

• More than 20 hours of Psychological Testing in a Single Year -  these are capped at 20 hours per person per year. Additional hours require prior authorization. These are billed under many different CPT codes, depending on the circumstances, including 96112, 96113, 96116, etc.

Where to Find Provider Resources for Handling Medicaid Claims for Addiction Treatment Services in Ohio 

Ohio’s Medicaid website maintains an entire page of resources for service providers. 

What Levels of Care Does Medicaid Cover for Addiction Treatment in Ohio? 

According to Ohio Administrative Code, Rule 5160-37-09, Substance use disorder treatment services, Medicaid will reimburse for the following levels of care: 

• Outpatient services in a “variety of settings.” This benefit covers no more than nine hours of services per week for adults and no more than six hours of services per week for adolescents. 

• Intensive outpatient and/or partial hospitalization services. This benefit extends to withdrawal management services and must provide services for those with co-occurring disorders. 

• Residential services and/or inpatient services. This level of care must also meet the needs of those with co-occurring disorders. Residential services must be overseen by providers who specialize in addiction treatment, mental health or general medical services 24 hours a day. As far as Medicaid is concerned, assessments, evaluations, crisis intervention, individual counseling, group counseling, family counseling, case management, peer recovery services, UAs and medical services are all considered to be part and parcel with residential treatment and they may not be billed separately. 

What Addiction Treatment Services are NOT Covered by Ohio Medicaid?

The following services will not be reimbursed by Ohio Medicaid under any circumstances: 

• Therapeutic behavioral services 

• Psychosocial rehabilitation 

• Community psychiatric supportive treatment 

• Mental health day treatment 

• Assertive community treatment 

• Intensive home based treatment 

What Addiction Treatment Services Limitations Are Placed on Medicaid Plans in Ohio?

There are several limitations that Ohio’s Medicaid program places on addiction treatment services but they are pretty “common sense” requirements. Most limitations revolve around prior authorization requirements, which were addressed earlier in this blog post. 

In addition to prior authorization requirements, Ohio’s Medicaid program stipulates that: 

• Patients may not receive more than one type of treatment at a time, eg, you can’t bill for residential treatment and outpatient treatment simultaneously. 

• All services must be medically necessary and medical necessity must be backed up with documentation. 

Other Blog Posts About the Addiction Treatment Business in Ohio

The Biggest Insurance Billing Mistakes Addiction Treatment Providers Make in Ohio

How to Open an Addiction Treatment Center in Ohio

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