Ohio behavioral health billing

Ohio behavioral health billing for community providers.

HRI bills Ohio Medicaid behavioral health claims, mental health and substance use, from enrollment through appeals: the state's rules and each plan's rules read together, authorization tracked to the date, and every claim reported each Friday.

Updated September 2026

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What Ohio billing runs on

One state manual and seven managed care plans, read together
Certification, then Medicaid enrollment in PNM, then plan contracts
Per diem and 15-minute units, and the July 2026 authorization limits
Every claim reported every Friday

How Ohio Medicaid pays behavioral health

Ohio Medicaid pays community behavioral health agencies under one state manual and seven managed care plans. The manual is ODM's Behavioral Health Provider Manual, version 1.28.1, published March 24, 2026. ODM writes it for fee-for-service, and it says the plans cover the same services and that you should read each plan's billing manual for the specifics. So a claim answers to two rulebooks: the state's codes, units and modifiers, and the plan's own rules for how authorizations and claims are submitted and paid.

The seven plans are AmeriHealth Caritas, Anthem, Buckeye, CareSource, Humana Healthy Horizons, Molina and UnitedHealthcare Community Plan. Where a claim goes depends on the patient: one of those plans, the OhioRISE plan for a youth enrolled in it, or ODM directly for a fee-for-service member. Ohio's Next Generation managed care program began on February 1, 2023.

The agency that certifies you is the Ohio Department of Behavioral Health (DBH), formerly the Ohio Department of Mental Health and Addiction Services, or OhioMHAS. It took the new name on October 1, 2025, so older guides, and some parts of the Administrative Code, still say OhioMHAS.

Before the first claim: accreditation, certification, enrollment, contracts

For a new agency the order is fixed, and each step needs the one before it: national accreditation, then DBH certification, then Ohio Medicaid enrollment, then a contract with each plan you want to bill.

National accreditation: Since October 3, 2023, under House Bill 33, a new community behavioral health provider seeking initial certification has to hold national accreditation for the services DBH says have accreditation standards. DBH recognizes CARF, the Council on Accreditation and The Joint Commission. Accreditation does not replace DBH certification.
DBH certification: You apply in DBH's Licensure and Certification Tracking System, LACTS, after you create an OH|ID account and request LACTS access. The standards are in Ohio Administrative Code chapters 5122-25 through 5122-29, and a certificate renews every three years.
Ohio Medicaid enrollment: Once certified, you apply through the state's Provider Network Management module, PNM. An agency enrolls as provider type 84 for mental health services and type 95 for substance use disorder services, or as both if it provides both. ODM adds or changes the provider specialty based on the certification documents you upload. Organizations can owe a non-refundable application fee, which is $750 per application for 2026, unless the fee was already paid to Medicare or another state's Medicaid program and you can document it.
Credentialing: PNM and the state's centralized credentialing began on October 1, 2022. ODM credentials Medicaid managed care providers once, at the state level, through a vendor, Maximus, not plan by plan. The state's FAQ lists community mental health centers and substance use disorder clinics among the provider types CMS requires to be credentialed, and credentialing repeats every 36 months.
Who signs: Your PNM Administrator starts the application and signs the provider agreement. There is one Administrator per NPI, and the Administrator can add an agent once the Medicaid ID has been issued.
Practitioners: Each rendering practitioner needs an NPI, enrolls in Ohio Medicaid and affiliates with your agency in PNM. Their personal NPI goes in the rendering field for each service on the claim.
Effective date and revalidation: A new provider agreement takes effect on the date the provider signs the application and meets the requirements. ODM can make that date retroactive for up to twelve months before the application if the provider was properly licensed or certified. Agreements must be revalidated no later than five years after the last one.
How long it takes: ODM publishes no processing time. Its new-provider FAQ says there is no formula for it, and that errors or missing documents put an application back at the end of the queue.

Enrollment and credentialing put you in ODM's system. They do not put you in a plan's network, and ODM's March 31, 2026 memo to the plans says a plan may pay only a provider who is enrolled with ODM and active in PNM. Medicare enrollment alone does not work for Next Generation MyCare Ohio: since January 1, 2026 the provider has to be enrolled with Ohio Medicaid before submitting claims.

Joining each plan

Every plan contracts with you separately, after you are enrolled, and each has its own process. This is what each plan's own page said on September 29, 2026.

CareSource: Fill out the New Health Partner Contract Form. CareSource also says providers who contract with it must be credentialed, and it points Ohio Medicaid providers to PNM for applications and credentialing requests. You are done when its welcome letter arrives with your CareSource ID.
Buckeye Health Plan: Buckeye's page says it is only expanding its network to support regulatory requirements and member access, and that contract requests are evaluated on provider type, specialty and geographic need. It has separate join forms for facility or agency, group and individual providers.
UnitedHealthcare Community Plan: Its behavioral health network runs through Optum. Optum's Ohio page says an agency that provides IOP or PHP to Medicaid-only members completes the Agency Application, and it gives an email address for questions about contracting and credentialing.
Molina Healthcare of Ohio: Be actively enrolled with ODM first, with every location current in PNM. Then email a completed Ohio Provider Contract Request Form to Molina's contract request address, and Molina sends the contracting documents. The guide lists medical, dental and vision paths and does not name behavioral health separately, so confirm with Molina which one applies to you.
Anthem Blue Cross and Blue Shield: You must be enrolled and credentialed through the state, with an active Ohio Medicaid number, before you contract. Anthem uses the provider data the state sends it.
AmeriHealth Caritas Ohio: The panel is closed except for behavioral health providers that are CANS providers, meaning they perform the Child and Adolescent Needs and Strengths assessment, and for vision exam providers. Other behavioral health providers are told to check back in six months.
Humana Healthy Horizons in Ohio: Apply through its behavioral health provider network application. You need an active Medicaid ID first, and Humana says you cannot render services to Medicaid members until Ohio Medicaid has fully screened, enrolled and, if required, credentialed you.
OhioRISE, Aetna Better Health of Ohio: Providers must enroll with Ohio Medicaid and contract with the OhioRISE plan. ODM's OhioRISE provider page lists Aetna's provider relations contacts.

The codes and units on an Ohio claim

Ohio's codes and units come from the state manual. These are the main codes for the programs this page covers, as the manual lists them. Rates are in the manual and change, so this page leaves them out. Confirm a plan's own rules before you submit.

H0015, SUD intensive outpatient: A per diem. The day counts when the group counseling runs at least 2 hours and 1 minute. ODM's June 2026 guidance puts the weekly requirement at 9 to 19 hours. Ohio treats the per diem as an unbundled service, so individual services can be billed the same day when medically necessary, and up to one hour of separate, distinctly different group service can sit beside it. A telehealth day carries the GT modifier.
H0015 with TG, SUD partial hospitalization: A per diem. The day needs at least 3 hours and 1 minute. Prior authorization is required. Partial hospitalization is a level of care of at least 20 hours of services a week: if the first four consecutive weeks fall short of 20 hours, the authorization is rescinded and services can still be paid at a lower level of care, not over 19.9 hours a week.
H2012 and H2020, mental health day treatment: Ohio bills mental health day treatment under the therapeutic behavioral group service. H2012 is hourly, up to two a day, for 0 to 2.5 hours. H2020 is a per diem for more than 2.5 hours.
H0005, SUD group counseling: A 15-minute unit. The manual sets a four-unit minimum, one hour, for H0005 billed with the AF or HK modifier. Beside an H0015 day, CareSource enforces a cap of four units.
H0036, CPST: Community psychiatric supportive treatment is billed in 15-minute units, individual or group with the HQ modifier. After six units in a day from the same agency, the remaining units pay at 50 percent.
H2019 and H2017, TBS and PSR: Therapeutic behavioral services (H2019) and psychosocial rehabilitation (H2017) are both 15-minute units. PSR needs the HM modifier, because without it H2017 reads as LPN nursing.
H0038, peer support: Certified peer supporters bill in 15-minute units, with an HQ modifier for a group. Up to four hours a day are paid without prior authorization.

For time-based codes, the manual applies the midpoint rule to the minimum billable service: divide the code's time by two and add one minute. H2017 is a 15-minute code, so a service needs at least 8 minutes to bill.

Same-day services, roll-up and supervision

When the same service is delivered to the same client by the same practitioner more than once in a day, the manual has you roll it into one detail line. The lines roll only if the date, client, HCPCS code, modifiers, rendering NPI, supervisor NPI and place of service all match. If anything but the time differs, report them separately. A service that should have rolled up and did not can deny as a duplicate.

Group services beside a per diem are limited. For adults, ODM allows up to one additional hour in total of group services on the same day as H0015, H0015 with TG, H2012 or H2020, if the services are separate, distinct and in the treatment plan: 90853, H0036 with HQ, H2019 with HQ, H0005 and H0038 with HQ. More than an hour needs prior authorization. So does mental health day treatment on the same day as SUD intensive outpatient or partial hospitalization, whether it comes from your agency or another.

A member who misses the per diem minimum is billed for the time attended. For mental health day treatment that is H2012. For SUD intensive outpatient or partial hospitalization it is H0005. Neither counts against the member's approved units.

For practitioners the manual lists under direct supervision, the supervisor's NPI on the claim is optional, but it changes the pay: the service pays at the supervisor's rate when the supervisor's NPI is in the claim header and at 72.25 percent of the maximum fee when it is not.

Medicaid is the payer of last resort. You bill the patient's other insurance first, except for the codes on ODM's Medicare and TPL Bypass List.

Prior authorization since July 2026

Ohio started prior authorization thresholds for community behavioral health services on July 1, 2026, and each plan has its own start date. Units count from July 1, even for a plan that starts enforcing on October 1. For now the thresholds apply only to community mental health agencies (type 84) and SUD agencies (type 95), not to hospitals or professional medical groups, and as of ODM's June 25, 2026 session it had not scheduled a start for fee-for-service. ODM's release says authorization is required only when services exceed reasonable thresholds, and that no service will be reduced or denied without an individualized clinical review.

The thresholds, per member per calendar year, except withdrawal management, which counts by episode:

Individual TBS (H2019) and PSR (H2017) share 200 units, 50 hours. Group TBS (H2019 with HQ) has 120 units, 30 hours.
TBS day treatment per diem (H2020) needs authorization after 30 units.
CPST (H0036) has 200 units for individual and 120 for group with HQ. Individual CPST is not combined with TBS or PSR.
SUD intensive outpatient (H0015) needs authorization after 30 units, and one unit is one program day.
SUD withdrawal management (H0010, H0011, H0012, H0014) needs authorization after the seventh consecutive day. UnitedHealthcare applies that rule only to H0011.

The count belongs to the member, not to your agency. It follows the member across providers and plans. ODM says a plan's count is only as current as the claims it has received, so another agency's late claim can put a member past a threshold that looked open. Each plan has its own way to look up a member's units, by portal, phone or email.

The plans start on different dates. July 1, 2026: Buckeye, CareSource, Humana and UnitedHealthcare for mental health and SUD, and Molina for mental health. October 1, 2026: AmeriHealth Caritas for both, and Anthem and Molina for SUD. January 1, 2027: Anthem for mental health.

Youth enrolled in OhioRISE and youth in the custody of a public children's services agency are exempt from the thresholds for TBS, PSR, CPST and TBS day treatment. Crisis services billed with the KX modifier are exempt too.

ODM tells providers not to wait for a denial. Send the request before the threshold, because a standard request can take up to 7 calendar days and an expedited one 2. Every plan has to accept ODM's two forms, the Community Behavioral Health Rehabilitative Services request and the SUD request. TBS, CPST and PSR approvals run 90 days. Day treatment per diem and SUD services are not; ODM says those need more frequent requests, in amounts tailored to the member. ODM also told providers that the thresholds plans announced in late 2025 and early 2026 are not valid, and that plans follow ODM's list.

OhioRISE and youth claims

OhioRISE began on July 1, 2022, for children and youth with complex behavioral health needs, and Aetna Better Health of Ohio runs it. For a youth enrolled in OhioRISE, ODM's mixed services protocol, effective July 1, 2026, sends all claims billed by community mental health agencies (type 84) and SUD agencies (type 95) to the OhioRISE plan, not to the youth's other managed care plan. Dental, transportation and other services that are not behavioral health stay with the youth's own plan or fee-for-service.

Aetna's OhioRISE plan takes electronic claims only, through EDI or its ConnectCenter portal. Enrollment in OhioRISE can start on any day of a month, so eligibility has to be checked for the date of service. Most behavioral health benefits under OhioRISE do not need prior authorization. Some services need a specialty added to your PNM enrollment first, among them the CANS assessment and mobile response and stabilization.

Where Ohio claims break

In every case below the care was delivered and the claim still failed.

Enrollment or affiliation not in place. Claims from a provider who is not enrolled and active in PNM are rejected at the state's electronic front door. Before a plan pays, both the billing provider and the rendering practitioner have to be active in PNM, and ODM rejects the plan's record of a claim when the two were never affiliated there.
Mental health and SUD codes under the wrong billing group. CareSource says claims for mental-health-only or SUD-only codes must go under the billing group NPI with the matching specialty, or they deny.
A threshold nobody counted. A member passes 30 program days or 200 units, no authorization is in place, and later claims deny. ODM's answer for a denial that came from an out-of-date count is a retroactive authorization or the plan's claim dispute process, plus a new request to continue services.
Too much group beside the per diem. Group time past one hour on an H0015 or day treatment day needs authorization. CareSource denies H0005 units past four.
A per diem billed for a short day. The day has to reach the per diem minimum. When it does not, the hourly or H0005 fallback applies.
Lines that should have rolled up, and missing supervisor NPIs. Separate lines for the same service, practitioner and place of service can deny as duplicates. A directly supervised service billed without the supervisor's NPI pays at 72.25 percent of the maximum fee.
Other insurance not billed first. A patient with other coverage has to be billed there before Medicaid, unless the code is on the bypass list.
Youth claims sent to the wrong plan. For a youth enrolled in OhioRISE, behavioral health claims from types 84 and 95 go to Aetna, not to the youth's other plan.
A late claim. For fee-for-service, ODM has to receive a claim within 365 days of the date of service, and the clock does not restart when a denied claim is resubmitted. Plans have their own manuals, so read the filing window in each.
A partial hospitalization program that runs under 20 hours. If the first four weeks of a stay run under 20 hours a week, the authorization is rescinded and later days can pay only at a lower level of care.

What ODM has proposed for later

In July 2026 ODM held rule-review sessions and asked providers to respond. These are proposals, not rules, and today's manual and rules govern every claim. For community mental health services ODM floated removing CPST from rule 5160-27-02 and considered renaming TBS day treatment "MH day treatment." For SUD services it floated restructuring IOP and PHP, for example as a bundled code instead of a per diem, and clarifying that only one per diem service can be billed per recipient per day, whether by the same billing agency or a different one.

What we do about it

HRI runs Ohio behavioral health billing under HRI Managed. That means benefit verification, authorization and concurrent review tracked to the date, and claims built to the state manual and each plan's rules before they go out. In Ohio it also means watching each member's units against the July 2026 thresholds and getting the request in before the threshold, not after the denial. A denied or stuck claim runs through the same seven-point diagnostic we apply to every claim. Every claim is reported to you every Friday, with its status, its age and the next action.

Opening an Ohio program

Accreditation and DBH certification decide when you can enroll, so start there. We prepare the PNM screens and the plan contract requests and track each one to a decision. Your organization's PNM Administrator signs the Medicaid provider agreement.

ODM can make an effective date retroactive up to twelve months, and its memo to the plans says providers and affiliations must be active on the date of service for original claims to be paid. We do not bill for a date of service before the effective date the state and the plan have confirmed. One rule is fixed: no claim goes to a payer until that payer confirms enrollment and an effective date. The order of work, what to have ready and the first 90 days are on the new-program billing page.

What it costs

Ohio billing is priced the same way as the rest of our billing, by who pays the claim. Any claim Ohio Medicaid pays, in whole or in part, through ODM, a managed care plan or the OhioRISE plan, carries a flat fee per claim, set per program day or per encounter where that fits, with a monthly minimum. The Medicaid fee is never a percentage of what is billed or collected, and it is owed whether or not the claim pays. Commercial insurance and Medicare claims carry a monthly minimum or a percentage of what payers pay, whichever is greater, never both. Every rate is fixed in writing before the first claim. Payers pay you directly, and we never receive payer money. Ending the agreement early outside its own exit terms carries an early-exit fee, set in the agreement. There is no setup fee when your operation is ready as it stands. Credentialing and enrollment work is priced separately, per service, in writing.

On Ohio Medicaid claims, your fee follows the claims we file, not what payers pay. Your exact numbers are set on a written quote after a billing review.

What HRI will not do

We will not promise a plan's authorization decision, a reimbursement rate, or an enrollment or certification date. Those calls belong to the plan, ODM and DBH. We will not bill an Ohio claim before enrollment and an effective date are confirmed. And we have no say in what level of care a patient gets: that decision belongs to your clinical team.

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Ohio billing, answered

What Ohio providers ask about billing.

What do we need before Ohio Medicaid will pay a new behavioral health agency?

Four things, in order. First, national accreditation, which the Ohio Department of Behavioral Health has required of new community providers since October 3, 2023. Second, DBH certification. Third, Ohio Medicaid enrollment through the state's PNM module, as provider type 84 for mental health, type 95 for substance use disorder, or both. Fourth, a contract with each managed care plan you want to bill. Enrollment and credentialing are ODM's, and they do not put you in any plan's network.

Do we enroll as provider type 84 or 95?

Type 84 is for mental health services and type 95 is for substance use disorder services. An agency that provides both enrolls as both. The types matter on the claim too: CareSource says mental-health-only or SUD-only codes must go under the billing group NPI with the matching specialty, or the claim is denied.

How long does Ohio Medicaid enrollment take?

ODM publishes no processing time, and its new-provider FAQ says there is no formula for it. Errors or missing documents send an application back to the end of the queue. The dates ODM does publish are different ones: an effective date that can be made retroactive for up to twelve months if you were properly licensed or certified, credentialing every 36 months, and revalidation no later than every five years.

What changed in Ohio prior authorization in 2026?

ODM set one list of thresholds for all managed care plans, starting with dates of service on July 1, 2026. A member needs authorization after 30 units of SUD intensive outpatient (H0015), 30 units of TBS day treatment (H2020), 200 units of individual CPST, or 200 units of individual TBS and PSR combined, with lower limits for group services and a seventh-day limit for withdrawal management. The count is per member and follows the member across providers and plans. Buckeye, CareSource, Humana and UnitedHealthcare started July 1, as did Molina for mental health. The start date is October 1, 2026 for AmeriHealth Caritas and for Anthem and Molina SUD services, and January 1, 2027 for Anthem mental health services.

How are PHP and IOP billed to Ohio Medicaid?

SUD intensive outpatient is billed as H0015 and SUD partial hospitalization as H0015 with the TG modifier, both as per diems. The day needs at least 2 hours and 1 minute for intensive outpatient and 3 hours and 1 minute for partial hospitalization. Partial hospitalization needs prior authorization and at least 20 hours of services a week. Mental health day treatment is H2012 by the hour up to 2.5 hours and H2020 as a per diem beyond that. For adults, up to one hour of separate group service can be billed on the same day as a per diem, and more needs authorization.

Who do we bill for a child enrolled in OhioRISE?

The OhioRISE plan, Aetna Better Health of Ohio. ODM's mixed services protocol, effective July 1, 2026, sends all claims billed by community mental health agencies (type 84) and SUD agencies (type 95) for an enrolled youth to that plan, not to the youth's other managed care plan. You have to be enrolled with Ohio Medicaid and contracted with the OhioRISE plan, and Aetna takes electronic claims only.

Do you charge a percentage?

Not on Medicaid claims. Any claim Ohio Medicaid pays, in whole or in part, through ODM, a managed care plan or the OhioRISE plan, carries a flat fee per claim, set per program day or per encounter where that fits, with a monthly minimum, never a percentage of what is billed or collected, and owed whether or not the claim pays. On commercial insurance and Medicare claims, we charge a monthly minimum or a percentage of what payers pay, whichever is greater, never both. Every rate is fixed in writing before the first claim goes out, and payers pay you directly.

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Last updated: September 29, 2026