Ohio Admin. Code 5160-27-02 - Coverage and limitations of behavioral health services
(A) This rule sets
forth coverage and limitations for behavioral health services rendered to
medicaid recipients by behavioral health provider agencies who meet all
requirements found in agency 5160 of the Administrative Code unless otherwise
specified.
(1) All claims for behavioral
health services submitted to the Ohio department of medicaid (ODM) must include
an ICD-10 diagnosis of mental illness or substance use disorder. The list of
recognized diagnoses can be accessed at
www.medicaid.ohio.gov.
(2) Medicaid reimbursable behavioral health
services are limited to medically necessary services defined in rule
5160-8-05
of the Administrative Code and Chapter 5160-27 of the Administrative Code.
Providers shall follow the requirements in rule
5160-8-05
of the Administrative Code and Chapter 5160-27 of the Administrative Code
regarding services that cannot be billed in combination with other
services.
(B) The
following services have limitations on the amount, scope or duration of service
that can be rendered to a recipient within a certain timeframe. These limits
can be exceeded with prior authorization from ODM or its designee.
(4)(3) Community
psychiatric supportive treatment (CPST) services as defined in rule
5122-29-17
of the Administrative Code and meet the following requirements:
(5)(4) Psychiatric
diagnostic evaluation and psychiatric diagnostic evaluation with medical
services are each limited to one encounter per recipient, per billing provider,
per calendar year.
(1) Screening, brief intervention and
referral to treatment (SBIRT) as defined by the American medical association's
current procedural terminology book. Limitation for this service is one per
code, per recipient, per billing provider, per calendar year.
(2) Assertive community treatment (ACT) as
defined in rule
5160-27-04
of the Administrative Code is available on or after the date as determined by
prior authorization approval.
(3) Intensive home based treatment
(IHBT) as defined in rule
5160-27-05
of the Administrative Code is available on or after the date as determined by
prior authorization approval.
(a) All CPST services provided in social,
recreational, vocational, or educational settings are allowable only if they
are documented mental health service interventions addressing the specific
individualized mental health treatment needs as identified in the recipient's
individualized service plan.
(b) A
billable unit of service for CPST may include either
face-to-face or telephone contact between the mental health
professional and the recipient or an individual essential to the mental health
treatment of the recipient.
(c)
CPST services are not covered under this rule when provided in a hospital
setting, except for the purpose of coordinating admission to the inpatient
hospital or facilitating discharge from an inpatient
hospital.
to the community following inpatient
treatment for an acute episode of care.
(d) Medicaid reimbursement of CPST services
is described in rule
5160-27-03
of the Administrative Code.
(C)
The following services delivered to recipients with substance use disorders
have limitations on the amount, scope or duration of service that can be
rendered to a recipient within a certain timeframe. These limits can be
exceeded with prior authorization from the ODM designated entity.
(1) Substance use disorder assessment as
referenced in rule
5160-27-09
of the Administrative Code is limited to two assessments per recipient, per
billing agency, per calendar year.
(2) Substance use disorder urine drug
screening as referenced in rule
5160-27-09
of the Administrative Code, is limited to one per day, per recipient.
(3)
Substance use
disorder peer
Peer recovery support as
referenced in rules
5160-27-09
and
5160-43-04
of the Administrative Code is limited to four hours per day per
recipient.
(4) Substance use
disorder partial hospitalization as described in rule
5160-27-09
of the Administrative Code.
is available on or after the date as determined by
prior authorization approval. The prior authorization request must substantiate
that the recipient meets the partial hospitalization level of care of twenty or
more hours of service per week. In accordance with rule
5160-1-27
of the Administrative Code ODM may retrospectively review the case that the
number of hours of service delivered matches the approved level of
care.
(5) Substance use
disorder residential level of care as described in rule
5160-27-09
of the Administrative Code.
is available for up to thirty consecutive days
without prior authorization per medicaid recipient for the first and second
admission, during the same calendar year. If the stay continues beyond thirty
days of the first or second stay, prior authorization is required to support
the medical necessity of continued stay. If medical necessity is not
substantiated and not approved by the ODM designated entity, only the initial
thirty consecutive days will be reimbursed. Third and subsequent admissions
during the same calendar year must be prior authorized by the ODM designated
entity from the date of admission.
(D) The medications listed in the appendix to
rule
5160-27-03
or appendix DD to rule
5160-1-60 of the
Administrative Code are covered by ODM when rendered and billed by an eligible
provider as described in rule
5160-27-01
of the Administrative Code. The medication must be administered by a qualified
practitioner acting within their professional scope of practice.
(E) Laboratory services, vaccines, and
medications administered in a prescriber office may be administered in
accordance with rule
5160-1-60 of the
Administrative Code.
(F) Medical
and evaluation and management services stated in the appendix to rule
5160-27-03
of the Administrative Code or appendix DD to rule
5160-1-60 of the
Administrative Code are covered by ODM when rendered by:
(1) A practitioner as described in paragraphs
(A)(3) and (A)(4) of rule
5160-27-01
of the Administrative Code and operating within their scope of practice;
or
(2) A pharmacist, rendering
services in accordance with rule 5160-8-52 of the Administrative
Code.
(G) CMS place of
service code set descriptions may be found at www.cms.gov. The department further defines
place of service 99 as "community," and this place of service may only be used
when a more specific place of service is not available. Place of service 99
shall not be used to provide services to a recipient of any age if the
recipient is being held in a public institution as defined in
42 C.F.R.
435.1010 (October 1, 2016).
(H) The activities that comprise or are
included in the aforementioned medicaid reimbursable behavioral health services
must be intended to achieve identified treatment plan goals or objectives.
Providers shall maintain treatment records and progress notes as specified in
rules 5160-01-27 and
5160-8-05
of the Administrative Code. A treatment plan for mental health services may
only be developed by a practitioner who, at a minimum, meets the practitioner
requirements found in paragraph (A)(6)(a) of rule
5160-27-01
of the Administrative Code. A treatment plan for substance use disorder
services may only be developed by a practitioner who, at a minimum meets the
practitioner requirements found in paragraph (A)(6)(b)(i) or (A) (6)(b)(iii) of
rule
5160-27-01
of the Administrative Code.
(I) The
medications and services listed in the appendix to rule
5160-27-03
of the Administrative Code or the opiate treatment service section of appendix
DD to rule
5160-1-60 of the
Administrative Code are reimbursed by the department when rendered and billed
by an opiate treatment program as described in Chapter 5122-40 of the
Administrative Code and licensed as such by the Ohio department of mental
health and addiction services and/or federally certified as such as stated in
42 CFR
8.11 (October 1, 2016). Reimbursement rates
are determined by the methodology described in paragraph (E) of rule
5160-4-12
of the Administrative Code or as listed in the appendix to rule
5160-27-03
of the Administrative Code or as listed in appendix DD to rule
5160-1-60 of the
Administrative Code.
(J) When
permitted, provision of any service addressed in Chapter 5160-27 of the
Administrative Code by telehealth as defined in rule
5122-29-31 of the
Administrative Code, must comply with the appropriate telehealth requirement(s)
found in rule
5160-1-18 of the
Administrative Code.
(K) The
services described in this chapter shall not substitute or supplant natural
supports and do not include any of the following:
(1) Educational, vocational, or job training
services.
(2) Room and
board.
(3) Habilitation services
including but not limited to financial management, supportive housing,
supportive employment services, and basic skill acquisition services that are
habilitative in nature.
(4)
Services to recipients who are being held in a public institution as defined in
42 C.F.R.
435.1010 (October 1, 2016);
(5) Services to individuals residing in
institutions for mental diseases as described in
42 C.F.R.
435.1010 (October 1, 2016);
(6) Recreational and social activities,
including but not limited to art, music, and equine therapies;
(7) Services that are covered elsewhere in
agency 5160 of the Administrative Code; and
(8) Transportation for the recipient or
family.
(L) Peer
recovery services as defined
as peer support services in rule
5122-29-15
of the Administrative Code are covered when delivered:
(1) Through the specialized recovery services
program in accordance with rule
5160-43-04
of the Administrative Code; or
(2)
As a component of assertive community treatment as defined in rule
5160-27-04
of the Administrative Code: or
(3)
As a component of substance use disorder residential treatment as defined in
rule
5160-27-09
of the Administrative Code; or
(4)
As a substance use disorder outpatient treatment service in accordance with
rule
5160-27-09
of the Administrative Code.
; or
(5)
As a component of
intensive home-based treatment service as defined in rule
5122-29-28
of the Administrative Code; or
(6)
As a component of
mobile response and stabilization service in accordance with rule
5122-29-14 of the
Administrative Code.
(M)
The "Ohio
children's initiative brief CANS assessment" and the "Ohio children's
initiative comprehensive CANS assessment" are covered as defined in rule
5160-59-01 of the Administrative Code and may be billed separately for
reimbursement. Payment for CPST, therapeutic behavioral services, or
psychiatric diagnostic evaluation is not allowable for provision of the Ohio
brief or Ohio comprehensive CANS assessment.
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02, 5162.05, 5162.02
Rule Amplifies: 5164.02, 5164.88, 5164.76, 5164.15, 5164.03
Prior Effective Dates: 01/01/2018, 01/02/2018 (Emer.), 05/03/2018, 06/12/2020 (Emer.), 01/17/2021, 07/09/2021
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