MedicaidPrior AuthHigh impact
[Ohio] Behavioral Health Service Frequency Guidelines
CareSource·OH · Psychiatry, General Practice·Specialty Services
Effective date
Jul 1, 2026
We identified it
May 30, 2026
Summary
Effective July 1, 2026, CareSource Ohio Next Generation MyCare & Medicaid is implementing new service frequency thresholds for behavioral health services. Prior authorization will be required once members exceed specified unit/day limits for withdrawal management, intensive outpatient programs, psychiatric support, and therapeutic services. Billing teams must track member utilization across all providers and obtain prior auth before services exceed thresholds to avoid claim denials.
Action Required
By June 30, 2026: (1) Billing team must implement tracking system to monitor member utilization for all behavioral health codes (H0010, H0011, H0012, H0014, H0015, H0036, H2017, H2019, H2020) across the calendar year. (2) Configure billing software to automatically flag and require prior authorization when thresholds are met: H0010/H0011/H0012/H0014 after 7 consecutive days; H0015/H2020 at 30 units per calendar year; H0036 at 200 units (50 hours) individual or 120 units (30 hours) group per calendar year; H2017/H2019 at 200 units (50 hours) combined or 120 units (30 hours) group per calendar year. (3) Register all billing and clinical staff in the CareSource Provider Portal to access real-time member utilization reports. (4) Update clinical protocols to require providers to verify member's total utilization from all providers before rendering services. (5) Establish internal workflow requiring prior authorization submission with 7-day turnaround expectation for most services and 48-hour turnaround for withdrawal management codes. Failure to obtain prior authorization before service thresholds are exceeded will result in claim denials. Utilization prior to July 1, 2026 will not count toward new thresholds.