[Ohio] Behavioral Health Prior Authorization Requirements - Substance use disorder (SUD) services and levels of care (LOC)

By September 15, 2026: Billing and clinical teams must implement the following changes for Ohio Medicaid and MyCare Ohio claims: (1) Update billing system rules to automatically require prior authorization for H0015 and G0137 (SUD IOP services) after 30 days of use per calendar year; (2) Configure system to require PA for H0010, H0011, and H0012 (Acute Detoxification/Withdrawal Management) after 7 days per episode of care, noting that consecutive billing without service gaps exceeding 24 hours counts as a single continuous event; (3) Train providers and billing staff that services billed with KX crisis modifier are excluded from service thresholds and do not trigger PA requirements; (4) Establish process to submit PA requests through Availity Essentials (preferred method) or designated fax lines (866-577-2184 for expedited, 866-577-2183 for standard); (5) Set calendar reminders to submit PA requests at least 7 days before IOP/PHP authorization expiration and at least 48 hours before detoxification authorization expiration to avoid claim processing delays; (6) Communicate with behavioral health providers that failure to obtain required prior authorization will result in claims being denied. Consequences of inaction: Claims for IOP and detoxification services exceeding thresholds without prior authorization will be denied and not processed.