POLICY AND PROCEDURE

POLICY STATEMENT:
The policy provides an overview of Buckeye’s utilization management approach for Therapeutic Behavioral Services (TBS) and Psychosocial Rehabilitation (PSR).

PURPOSE:
This policy addresses the claim payment, eligibility, documentation and other requirements related to Therapeutic Behavioral Services (TBS) and Psychosocial Rehabilitation (PSR).

Therapeutic behavioral services (TBS) and psychosocial rehabilitation (PSR) services are an array of activities intended to provide individualized support or care coordination of healthcare, behavioral healthcare, and non-healthcare services. TBS and PSR may involve collateral contacts and may be delivered in all settings that meet the needs of the individual.

TBS and PSR must be medically necessary and comply with Ohio Administrative Code (OAC) 5122-29-18 and Ohio Department of Medicaid (ODM) regulations. OAC and ODM regulations establish TBS and PSR requirements including what constitutes TBS and PSR activities, specialist qualifications, supervision requirements, training requirements, and medical record documentation requirements, among other requirements.

SCOPE:
This policy applies to all directors, officers, employees of Buckeye Health Plan, and external providers.

POLICY:
Background:

Therapeutic Behavioral Services (TBS)

Therapeutic Behavioral Services are short-term, individualized, intensive interventions provided to individuals with significant emotional or behavioral challenges. The purpose of TBS is to reduce severe behaviors, prevent crises, and avoid the need for higher levels of care such as inpatient hospitalization or residential treatment. Services focus on implementing behavior management strategies, reinforcing coping skills, and supporting the transfer of therapeutic goals into real-world settings. TBS are delivered under the supervision of a licensed clinician to supplement, not replace, ongoing therapy.

Psychosocial Rehabilitative Services (PSR)

Psychosocial Rehabilitative Services are recovery-focused, skills-based interventions intended to help individuals with serious mental illness or behavioral health conditions develop social, emotional, and daily living skills needed for independent functioning and community integration. PSR emphasizes building coping skills, improving interpersonal relationships, supporting illness self-management, and enhancing vocational and educational readiness. Services are person-centered, strengths-based, and delivered in home or community settings to promote resilience and sustained recovery.

Service Activities

TBS services activities may include, but are not limited to:

((a) Consultation with a licensed practitioner or an eligible provider pursuant to paragraph (C) of this rule, to assist with the individual’s needs and service planning for individualized support or care coordination of healthcare, behavioral healthcare, and non-healthcare services and development of a treatment plan;
(b) Referral and linkage to other healthcare, behavioral healthcare, and non-healthcare services to avoid more restrictive levels of treatment;
(c) Interventions using evidence-based techniques;
(d) Identification of strategies or treatment options;
(e) Restoration of social skills and daily functioning; and,
(f) Crisis prevention and amelioration.

PSR service activities include, but are not limited to the following

(a) Restoration, rehabilitation and support of daily functioning to improve self-management of the negative effects of psychiatric or emotional symptoms that interfere with a person’s daily functioning;
(b) Restoration and implementation of daily functioning and daily routines critical to remaining successfully in home, school, work, and community; and,
(c) Rehabilitation and support to restore skills to function in a natural community environment.

Services should be provided in a culturally inclusive and competent manner which includes not practicing, condoning, facilitating, or collaborating in any form of discrimination based on ethnicity, race, gender, sexual orientation, age, religion, national origin, marital status, political belief, or mental or physical disability.

TBS and PSR services shall be provided a person certified in accordance with in rule 5160-02-18 of the Administrative Code.

Eligible Provider Requirements OAC 5122.29.15:

Eligible providers of TBS are those practitioners who have :
(a) A bachelor’s or master’s degree in social work, psychology, nursing, or in related human services, or
(b) A high school diploma with a minimum of three years of relevant experience.

(2) Eligible providers for PSR services are those practitioners who have a high school diploma and specific training related to people with mental health conditions or needs.

PROCEDURE:

1. TBS and PSR should be supplemental to actual clinical services and should not be used to replace clinically based programming, i.e. outpatient psychotherapy, intensive outpatient program (IOP), partial hospitalization, or residential treatment.
2. TBS and PSR should be individualized and member-centric to meet the member’s needs as specified in the member’s plan of care.
3. Members receiving TBS and PSR should meet the requirements of ASAM Adult Level 1 Outpatient Criteria if for a member with a substance use disorder (SUD), InterQual Outpatient Criteria for a member with a mental health disorder, or OAC requirements for services.
4. Components of TBS and PSR must include:
   a. Restorative and rehabilitative interventions aimed to social and independent functioning and community integration.
   b. Support is structured and scheduled, non-clinical but involves therapeutic activities that promote socialization, recovery, self-advocacy, preservation and enhancement of community.
5. The amount of TBS and PSR provided should decrease over time as a treatment goal is for the member to demonstrates self-management skills.

Prior Authorization:

TBS:

H2020 (Group Per Diem) is limited to 1 per day. Prior authorization is required for an additional per diem service to the same client on the same day rendered by a different billing agency. Services exceeding 25 units require prior authorization.

H2019 (15 min units) is limited to 8 units per day by the same agency. Services exceeding 80 units (total billed)/calendar year require prior authorization.

PSR:

H2017 (15 min units) is limited to 8 units per day by the same agency. Services exceeding 120 units (total billed)/calendar year require prior authorization.

Services delivered above these limits are subject to utilization review and require a prior authorization.

8. If the provider submits medical records and documentation within 30 days of the request, and the medical records demonstrate that the additional services were medically necessary and appropriate based on the member’s diagnosis and meets the regulatory requirements, Buckeye will adjust the claim for payment (provided that CMS, NCCI, and other standing coding guidelines are met).
9. If the provider submits medical records and documentation that do not demonstrate that additional services were medically necessary and appropriate based on the member’s diagnosis or does not demonstrate that regulatory requirements were met, the claim will remain denied.

Evidentiary Support for Therapeutic Behavioral Services (TBS) and Psychosocial Rehabilitative Services (PSR)

Buckeye establishes utilization management parameters for Therapeutic Behavioral Services (TBS) and Psychosocial Rehabilitative Services (PSR) based on evidence-informed practice guidelines, published research, and comparative analysis of Medicaid policies across multiple states. Duration limits and authorization criteria are intended to ensure access to clinically appropriate, time-limited interventions that promote recovery, skill development, and transition to less intensive levels of care.

Therapeutic Behavioral Services (TBS)
Evidence Base:

• State Medicaid programs generally define TBS as a short-term, intensive behavioral intervention intended to support stabilization and prevent higher levels of care. These programs commonly authorize TBS in time-limited increments (e.g., 30-day or monthly periods) with an emphasis on measurable progress and transition planning.
• Research on community-based behavioral health interventions indicates that the average course of treatment includes approximately twenty (20) to twenty-five (25) sessions, aligning with evidence that TBS is most effective when delivered as a structured, episodic intervention (Triplett et al., 2021).

Proposed Duration Parameters:

In alignment with SAMHSA-supported practices, the typical course of TBS treatment is expected to range from three (3) to four (4) months, generally encompassing twenty (20) to twenty-five (25) sessions. These standards reflect evidence-based treatment patterns and may serve as a basis for setting prior authorization and continued-stay review thresholds.

Psychosocial Rehabilitative Services (PSR)
Evidence Base:

• State Medicaid programs and national literature describe PSR as a structured, time-limited, and goal-oriented service designed to improve functioning and promote community integration. Services are typically brief and focused on measurable outcomes, with reauthorization contingent upon demonstrated progress.
• Empirical research supports treatment periods of approximately three (3) to four (4) months, or a minimum of six (6) structured sessions, as adequate to achieve functional and rehabilitative goals (Yildiz, 2021).

Proposed Duration Parameters:

Based on SAMHSA guidance and consistent with observed practice standards, PSR services are generally delivered over a three (3) to four (4)-month period, emphasizing recovery, skill development, and member self-sufficiency. Services extending beyond six (6) months should include documented justification of continued medical necessity and evidence of ongoing progress.

Rationale:

These proposed duration parameters reflect national evidence and Medicaid trends supporting structured, time-limited behavioral health interventions. This approach promotes alignment with SAMHSA’s principles of individualized, person-centered care while ensuring appropriate utilization management oversight and timely transition to less intensive services when clinically appropriate.

Coding Implications

This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2024, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

ATTACHMENTS:

ROLES & RESPONSIBILITIES:

REGULATORY REPORTING REQUIREMENTS:
Ohio Department of Medicaid

REVISION LOG

POLICY AND PROCEDURE APPROVAL

The electronic approval retained in RSA Archer, the Company’s P&P management software, is considered equivalent to a signature.

Important Reminder
This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice;

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peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract to guarantee payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions, and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

This clinical policy does not constitute medical advice, medical treatment, or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care and are solely responsible for the medical advice and treatment of members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollees. Members/Enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein is strictly prohibited. Providers, members/enrollees, and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services.

Note: For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

Note: For Medicare members/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.

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