MedicaidPrior AuthMedium impact
5160-59-03.1 - OhioRISE: utilization management. (Amend/Final File)
Ohio Medicaid·OH · Psychiatry, Pediatrics, Family Medicine·Managed Care
Effective date
Jan 1, 2026
We identified it
Jun 20, 2026
Summary
Ohio Department of Medicaid has amended Rule 5160-59-03.1 regarding OhioRISE utilization management requirements. This is a managed care policy update that will take effect January 1, 2026, affecting providers who serve OhioRISE members in Ohio's specialized managed care program for children and youth with complex behavioral health and multi-system needs.
Action Required
Before January 1, 2026: Providers serving OhioRISE members in Ohio must review and implement updated utilization management requirements per amended Rule 5160-59-03.1. Contact Ohio Department of Medicaid at 614-752-3877 for specific implementation guidance. Billing teams should verify current authorization processes align with new requirements to avoid claim denials.