Ohio behavioral health billing

Ohio behavioral health billing for community providers.

Ohio Medicaid's managed care plans all follow one state list of behavioral health authorization thresholds, starting with dates of service on July 1, 2026. Health Revenue Intelligence (HRI) bills Ohio Medicaid for mental health and substance use agencies, from PNM enrollment through appeals.

Updated October 2026

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What Ohio billing runs on

One state manual, seven managed care plans and OhioRISE
Accreditation and state certification before PNM enrollment and plan contracts
Per diem days, 15-minute units and the July 2026 thresholds
A Friday report on every Ohio claim: where it stands, how old it is, what happens next

How we run Ohio billing

Under HRI Managed, we count each member's units against the thresholds set by the Ohio Department of Medicaid (ODM). Authorization requests go in before a member reaches a threshold. We also check benefits and track each concurrent review against the plan's date. The claims we send carry the state manual's codes and units and follow each plan's own rules for submission and payment. Any Ohio claim that is denied or stuck goes through our seven-point diagnostic.

What it costs

Your exact numbers are set on a written quote after a billing review.

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 the Ohio Department of Medicaid's (ODM) Behavioral Health Provider Manual, version 1.28.1, published March 24, 2026. ODM writes it for fee-for-service, where ODM pays the claim. The manual says the plans cover the same services and sends providers to each plan's billing manual for the specifics. 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 Ohio Department of Behavioral Health (DBH) certifies behavioral health agencies. It was formerly the Ohio Department of Mental Health and Addiction Services, or OhioMHAS, and took the new name on October 1, 2025. Older guides, and some parts of the Administrative Code, still say OhioMHAS.

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

A new agency follows a fixed order: national accreditation, then DBH certification, then Ohio Medicaid enrollment, then a contract with each plan it wants to bill. Each step needs the one before it.

National accreditation: Since October 3, 2023, House Bill 33 has required a new community behavioral health provider seeking initial certification to hold national accreditation. The requirement covers 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. A certificate renews every three years.
Ohio Medicaid enrollment: Once certified, you apply through the state's Provider Network Management (PNM) module. An agency enrolls as provider type 84 for mental health services and type 95 for substance use disorder (SUD) services, or as both if it provides both. ODM adds or changes the provider specialty from the certification documents you upload. An organization can owe a non-refundable application fee, $750 per application for 2026. The fee does not apply if it 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. The state's FAQ lists community mental health centers and substance use disorder clinics among the provider types the federal agency CMS requires to be credentialed. Credentialing repeats every 36 months.
Who signs: Your PNM Administrator starts the application and signs the provider agreement. Each National Provider Identifier (NPI) has one Administrator, who 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. 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 a provider rendering services to Next Generation MyCare Ohio members 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. Each entry is what that plan's own page said on September 29, 2026, except OhioRISE, which follows ODM's guidance.

CareSource: CareSource asks for its New Health Partner Contract Form and says providers who contract with it must be credentialed. It points Ohio Medicaid providers to PNM for applications and credentialing requests. The process ends with a welcome letter that carries the provider's CareSource ID.
Buckeye Health Plan: Buckeye's page says it is only expanding its network to support regulatory requirements and member access. It says 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 intensive outpatient (IOP) or partial hospitalization (PHP) to Medicaid-only members completes the Agency Application. The page also gives an email address for questions about contracting and credentialing.
Molina Healthcare of Ohio: Molina requires active ODM enrollment first, with every location current in PNM. It takes a completed Ohio Provider Contract Request Form by email at its contract request address, then sends the contracting documents. Its guide lists medical, dental and vision paths and does not name behavioral health separately.
Anthem Blue Cross and Blue Shield: Anthem requires a provider to be enrolled and credentialed through the state, with an active Ohio Medicaid number, before contracting. It uses the provider data the state sends it.
AmeriHealth Caritas Ohio: The panel is closed except for vision exam providers and behavioral health providers that perform the Child and Adolescent Needs and Strengths (CANS) assessment. Other behavioral health providers are told to check back in six months.
Humana Healthy Horizons in Ohio: Humana takes applications through its behavioral health provider network application. An active Medicaid ID comes first. Humana says a provider cannot render services to Medicaid members until Ohio Medicaid has fully screened, enrolled and, if required, credentialed that provider.
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. Rates are in the manual and change.

H0015, SUD intensive outpatient: A per diem, which pays one amount for each program day. 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. Individual services can be billed the same day when medically necessary. 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. Services can still be paid at a lower level of care, up to 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

The manual has the provider roll a service into one detail line when the same practitioner delivers it to the same client more than once in a day. The lines roll only if the date, client, HCPCS service code, modifiers, rendering NPI, supervisor NPI and place of service all match. Lines that differ in anything but the time are reported separately. A service that should have rolled up and did not can deny as a duplicate.

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. The services must be separate, distinct and in the treatment plan, and they are 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.

When a member misses the per diem minimum, the agency bills 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. The service pays at the supervisor's rate when that 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. Providers bill the patient's other insurance, called third-party liability (TPL), first, except for the codes on ODM's Medicare and TPL Bypass List.

Prior authorization since July 2026

Ohio's prior authorization thresholds for community behavioral health services began on July 1, 2026. Units count from July 1, even for a plan that began enforcing on October 1. For now the thresholds apply only to community mental health agencies (type 84) and SUD agencies (type 95). The thresholds do not apply to hospitals or professional medical groups. As of ODM's June 25, 2026 session, ODM had not scheduled a start for fee-for-service. ODM's release says authorization is required only when services exceed reasonable thresholds. The release also says 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 and 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. The request goes in before the threshold is reached. A standard request can take up to 7 calendar days, and an expedited request up to 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 do not get 90-day approvals. ODM says those services 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. Aetna Better Health of Ohio runs it. For a youth enrolled in OhioRISE, all claims billed by community mental health agencies (type 84) and SUD agencies (type 95) go to the OhioRISE plan instead of 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. Both rules come from ODM's mixed services protocol, effective July 1, 2026.

Aetna's OhioRISE plan takes electronic claims only, through electronic data interchange (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

Ohio claims break at each of these points, all after the care has been delivered.

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. 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. Same-day group time past ODM's limit needs authorization, and H0005 units past CareSource's cap deny.
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 the lower rate set out under supervision above.
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 instead of 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. The clock does not restart when a denied claim is resubmitted. Plans have their own manuals, and each states its filing window.
A partial hospitalization program that runs under 20 hours a week. Its authorization depends on reaching those hours, as the H0015 with TG entry sets out.

What ODM has proposed for later

In July 2026 ODM held rule-review sessions on proposed rule changes and asked providers to respond. 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." On the SUD side it explored restructuring IOP and PHP, for example as a bundled code instead of a per diem. A further proposal would clarify that only one per diem service can be billed per recipient per day, whether by the same billing agency or a different one.

Opening an Ohio program

Accreditation and DBH certification decide when an agency can enroll, so the work begins there. Our part is the PNM screens and the contract request for each plan, and we follow every one until ODM or the plan answers. Your organization's PNM Administrator signs the Medicaid provider agreement.

ODM's memo to the plans says providers and affiliations must be active on the date of service for original claims to be paid. We bill nothing for a date of service before the effective date the state and the plan have confirmed. The new-program billing page sets out the order of work and what to have ready.

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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: national accreditation, certification by the Ohio Department of Behavioral Health, Ohio Medicaid enrollment in the PNM module, and a contract with each managed care plan you want to bill. Accreditation has been required of new community providers since October 3, 2023. You enroll as provider type 84 for mental health, type 95 for substance use disorder, or both. Enrollment alone does 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. Your provider agreement's effective date can be made retroactive for up to twelve months if you were properly licensed or certified.

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. Authorization is needed once a member's units pass a threshold, such as 30 program days of SUD intensive outpatient (H0015) or 200 units of individual CPST. The count follows the member across providers and plans. Buckeye, CareSource, Humana and UnitedHealthcare started July 1, as did Molina for mental health. AmeriHealth Caritas, and Anthem and Molina for SUD services, followed on October 1, 2026. Anthem mental health services start on January 1, 2027.

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.

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.

Billing Ohio Medicaid or about to?

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Last updated: October 25, 2026