Ohio Medicaid changes prior authorization rules for some behavioral health and substance-use services

Ohio Medicaid’s new threshold-based review system took effect July 1, 2026, for selected behavioral-health and substance-use services. Most covered care can begin without prior authorization, but a member may need approval to continue treatment after a service-specific annual limit or consecutive-day threshold is reached.

The change applies statewide to Medicaid members, behavioral-health providers and managed-care plans. It is not a blanket requirement that every behavioral-health visit receive approval. Individual managed-care plans may begin using the framework on July 1 or a later date, so members and providers should confirm the plan-specific start date, forms and submission process.

How the pass-through process works

Ohio Department of Medicaid officials describe the policy as a “pass-through.” Providers generally do not need an approved authorization to initiate a covered service. Authorization may be required when the member reaches the applicable limit and wants to continue receiving that service.

The threshold triggers a medical-necessity review. It does not automatically mean treatment will be denied. The review is intended to examine the member’s clinical needs, treatment plan and supporting documentation.

ODM says the framework is intended to improve coordination and oversight as behavioral-health service use has increased. The department has attributed the change to concerns about duplicated or layered services without sufficient clinical coordination. Those are ODM’s stated reasons for the policy, not an independent finding that every service affected by the rules is improper.

Services and thresholds that trigger review

For the initial rollout, services delivered before July 1, 2026, do not count toward the newly established thresholds. The principal limits below are calculated by calendar year unless otherwise noted:

• Therapeutic behavioral services, individual: after 200 units, or 50 hours, combined with psychosocial rehabilitation.
• Therapeutic behavioral services, group: after 120 units, or 30 hours.
• Therapeutic behavioral day treatment: after 30 units.
• Community psychiatric support treatment, individual: after 200 units, or 50 hours.
• Community psychiatric support treatment, group: after 120 units, or 30 hours.
• Psychosocial rehabilitation: after 200 combined units, or 50 hours, with individual therapeutic behavioral services.
• Substance-use intensive outpatient treatment: after 30 units.
• Ambulatory withdrawal-management services: after the seventh consecutive day.
• Clinically managed or medically managed residential withdrawal-management services: after the seventh consecutive day.

Some limits combine services. For example, units for individual therapeutic behavioral services and psychosocial rehabilitation are counted together. Providers may therefore need to track care delivered by more than one agency or provider. CareSource and Buckeye guidance directs providers to coordinate treatment and monitor cumulative utilization so a member does not unexpectedly reach a threshold.

Who and what is excluded

Some services and populations are excluded from the specified behavioral-health rehabilitation authorization requirements. They include crisis services billed with the KX modifier and behavioral-health nursing services provided under Ohio Administrative Code 5160-27-11.

Children and youth enrolled in OhioRISE, as well as children and youth in the custody of a public-child-welfare agency, are excluded from the specified behavioral-health rehabilitation authorization requirements. This is not a blanket exemption for every child or every behavioral-health service.

How quickly plans must respond

Standard authorization requests generally have a seven-calendar-day review timeframe. Designated withdrawal-management services have a 48-hour expedited review timeframe. Providers should submit standard requests at least seven days before the current authorization or threshold is exhausted when possible; expedited requests should generally be submitted at least two days in advance.

For approved behavioral-health rehabilitation services, managed-care plans must authorize at least 90 days unless the provider requests a shorter period. The 90-day rule applies to approved care; it does not guarantee approval or mean every authorization will last 90 days.

ODM requires managed-care plans to notify their provider networks at least 30 days before the effective date of changes to clinical-care policies involving service authorizations. Because plans may implement the statewide framework on different dates, members should rely on their plan’s current notice and instructions rather than assume every plan began on July 1.

What Medicaid members should do

Members receiving ongoing care should ask their provider whether the service is approaching a threshold and whether units from another provider or related service are included in the count. They should also ask whether a continuation request has been submitted and contact the managed-care plan to confirm the request’s status, effective date and required next steps.

If a plan denies or limits continued treatment, members can use the plan’s reconsideration and appeals procedures. The plan’s written notice should explain the decision and available next steps. Members should promptly ask their provider or plan what to do if a review is pending and scheduled care could be interrupted.

What providers should do

Providers should track cumulative units across providers and services, coordinate treatment when more than one agency is involved, and submit continuation requests before the threshold is exhausted whenever possible.

Requests should use Ohio Medicaid’s standardized forms and the member’s managed-care plan’s required submission system. Providers should include an updated treatment plan, measurable goals, the reason for the requested service intensity and documentation showing progress or an ongoing treatment need. Plan-specific portals and instructions may differ.

The new framework took effect July 1, 2026, but the operational rollout can vary by managed-care plan. For members, the immediate practical step is to ask both the provider and the plan whether a threshold has been reached before continued care is scheduled. For providers, early utilization checks and coordination across agencies can reduce the risk of an avoidable administrative interruption.

Key sources

• Ohio Department of Medicaid: New Prior Authorization Standards for Behavioral Health Services
• CareSource Ohio Medicaid: Community Behavioral Health Services Utilization Management Policy
• Buckeye Health Plan: Behavioral Health Provider Authorizations Information

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