Ohio Medicaid behavioral health prior authorization: 2026 thresholds

Ohio Medicaid behavioral health prior authorization changed on July 1, 2026. The Ohio Department of Medicaid (ODM) moved community behavioral health services to a pass-through model. An agency can start therapeutic behavioral services (TBS), psychosocial rehabilitation (PSR), community psychiatric support treatment (CPST), and the listed substance use disorder (SUD) services without an approved authorization. It needs one only to continue after the member reaches a calendar-year threshold.

The thresholds are set in units. For the hourly rehabilitation codes, a unit is 15 minutes, so 200 units equals 50 hours. Individual TBS and PSR share 200 units, individual CPST has its own 200, and group TBS and group CPST have 120 each. Managed care entities (MCEs) must authorize rehabilitation services for at least 90 days, and use before July 1, 2026 does not count.

This guide covers the threshold table, how pass-through authorization works day to day, what goes in the request, and the proposed rule changes that could move the numbers. It is written for owners, clinical directors, and billers at Ohio community behavioral health agencies, as of September 2026.

What changed on July 1, 2026

ODM announced the change in a provider bulletin on May 12, 2026, titled "Important Update: ODM Utilization Management Requirements Effective July 1." The core rule fits in two sentences from that bulletin. An approved authorization is not required to initiate a service. If the service limit is reached within the calendar year, an authorization is required to continue services.

Three other points from the bulletin shape daily work:

1. Plans must "authorize BH Rehabilitation services for a duration of at least 90 days."
2. "Utilization prior to July 1 will not count towards the newly established service thresholds."
3. ODM posted updated authorization forms on its behavioral health provider pages, and the plans use those same forms. That reduces plan-by-plan variation in what you send.

The services themselves are defined in Ohio Administrative Code (OAC) Chapter 5160-27. Medical necessity is defined in OAC 5160-1-01, and plans review requests against it.

The July 2026 threshold table

These are the calendar-year thresholds from the ODM bulletin. The last column is the expected MCE turnaround listed in the same table.

The word "combined" matters. Individual TBS and PSR draw from one 200-unit pool, not two. A member who received 120 units of TBS and 80 units of PSR has reached the threshold. The TBS vs PSR guide explains how to choose between the two services.

Compliance note: a threshold is not a cap on care. Past the threshold, services continue only under an approved authorization. Units delivered past the threshold without one are the units a plan can deny.

How pass-through authorization works in practice

Pass-through removes the front-end request. It moves the work to counting. Nobody sends you an alert that guarantees you will be warned in time, so the agency has to know where each member stands.

Count your own units

Keep a running total per member, per threshold pool, per calendar year, starting July 1, 2026 for this year. Count from signed service records, not from paid claims. Paid claims lag by weeks, and a member can cross 200 units while claims are still in process.

Build the count around the pools in the table, not around codes. H2019 and H2017 feed one pool. H0036 feeds another. The group codes each have their own.

Ask the plan for utilization to date

Your records show only your agency's services. The plan's policy may show more. UnitedHealthcare Community Plan's Ohio policy, for example, says the plan will give a community behavioral health center (CBHC) the member's utilization to date on request. It also warns that the figure is based on claims received and may not be real time.

That policy puts responsibility on providers to track service delivery for each member. It also says that when a member gets the same service from more than one provider, the providers must coordinate to avoid duplication and early exhaustion of units. Ask each plan how it counts before you rely on your own total alone.

Coordinate when another agency serves the member

Ask members at intake and at each treatment plan review whether they receive behavioral health services elsewhere. Record the answer. If they do, contact the plan early, well before your own count reaches the threshold.

Multi-state agencies will recognize the pattern. Minnesota's ARMHS hour threshold works the same way, and the MHCP service agreements and prior authorization guide walks through how Minnesota ties authorizations to claims.

What to put in the authorization request

For TBS, PSR, CPST, TBS Day Treatment, and peer support, use ODM 10406 (7/2026), the Community Behavioral Health Rehabilitative Services Authorization Request. For SUD residential, IOP, partial hospitalization, and withdrawal management, use ODM 10276, the Substance Use Disorder Services Prior Authorization Request.

ODM 10406 asks for member and provider details, including the billing agency's National Provider Identifier (NPI), the practitioner's NPI, and network status. For each service, you select the code, the reason (such as "service threshold met"), the units requested, and the start date. TBS, PSR, TBS Day Treatment, and CPST also require Section IV, a checklist of medical necessity criteria.

The form's instructions ask for these attachments:

• Service start date, referral source, and reason for services
• Clinical documentation, such as the assessment summary and the treatment plan with diagnostic summary
• Primary and secondary diagnoses, and psychosocial barriers to treatment
• Pertinent medical and behavioral health history, including suicide and homicide risk
• The treatment plan with target dates and a discharge plan

For continued stay requests, add new problems, how lack of progress is being addressed, and an updated discharge plan. The request is only as strong as the assessment and treatment plan behind it. The plan needs to see why this member needs this service, at this amount, now.

Timing matters too. UnitedHealthcare's policy asks for standard requests at least 7 days, and expedited requests at least 2 days, before the current authorization runs out. Check each plan's policy and portal for its own channel and timelines.

The 90-day minimum and what does not count

When a plan approves a behavioral health rehabilitation request, the authorization must cover at least 90 days. UnitedHealthcare's policy adds that a provider can ask for a shorter period. It also says the authorization ends when the approved units are used or the period expires, whichever comes first. So plan the units, not only the dates.

Some services and members sit outside the thresholds. The ODM bulletin excludes:

• Crisis services billed with the KX modifier
• Behavioral health nursing under OAC 5160-27-11
• Children and youth enrolled in the OhioRISE plan
• Children and youth in public child welfare custody

Use before July 1, 2026 does not count. Every member started calendar year 2026 at zero on July 1.

Audit tip: keep the dated count you relied on when you decided a request was not yet needed. If a plan later disputes a claim, that record shows the agency tracked the threshold in good faith.

How the proposed 2026 rule changes could shift the thresholds

At a stakeholder session on July 16, 2026, ODM presented a proposed strategy for the community behavioral health rules. It is proposed, not final. It includes removing CPST from rule 5160-27-02 and raising the TBS and PSR threshold to 200 units each, "in light of removing CPST as a service option." It also proposes removing the 90-minute rate reduction for TBS and PSR in rule 5160-27-03. Comments were due July 22, 2026.

If adopted, the combined TBS and PSR pool would split into two pools of 200 units. The Ohio CPST changes guide covers the proposal and what agencies billing H0036 should plan for. Until a final rule is filed, the July 1, 2026 table above applies.

Operational checklist for billers and clinical leads

Carry the authorization number onto the claim where the plan requires it. The 837P claim guide shows the fields, and Ohio plans use the same 837P format. Keep authorization packets under the same access controls as other clinical records, as the HIPAA compliance guide describes.

How Trustora helps

Trustora runs an Ohio Behavioral Health program on its configurable program runtime, alongside its Minnesota programs. Client records carry the Ohio Medicaid ID, and individual and group service records sit next to the assessments, treatment plans, and progress notes a plan asks for with an authorization request. Readiness checks run before a service record can become a claim, and claims are created only from signed service records.

Claims go out as 837P with the NPI and taxonomy, with 277CA acknowledgments and ERA (835) posting. Trustora does not submit authorizations to plans or track the July 2026 thresholds automatically. It keeps the signed records you count from and attach. See the Ohio behavioral health software page or contact the team to walk through your workflow.