Clinical Policy: Peer Support Services

Reference Number: OH.CP.BH.502
Date of Last Revision: 07/25

See Important Reminder at the end of this policy for important regulatory and legal information.

Description

This clinical policy outlines the medical necessity criteria for peer support services within Buckeye Health Plan based off guidance from the Ohio Legislative Service Commission and in accordance with Ohio Administrative Rule 5122-29-15: Peer recovery services and 5160-27-02: Coverage and limitations of behavioral health services.

Peer support services provide support to member/enrollees with a mental illness, intellectual or developmental disabilities, or substance use disorders and their caregivers and families. These services promote resiliency and recovery, self-determination, advocacy, well-being, and skill development.¹

Background

Peer support services are individualized, resiliency and recovery focused, and based on increasing knowledge and skills through a peer relationship that supports an individual’s or family’s ability to address needs, navigate systems and promote recovery, resiliency, and wellness. They promote family driven, youth guided, trauma informed care and cultural humility, encourage partnership with individuals and families, and advocate for informed choice.¹

The Ohio Administrative Rule 5122-29-15: Peer Support Services¹

Definitions

1. “Recovery” means the personal process of change in which an individual strives to improve their health and wellness, resiliency, and reach their full potential through self-directed actions.
2. “Resiliency” means the ability to recover from setbacks, adapt well to change, and keep going in the face of adversity. It is the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress such as family and relationship problems, serious health problems, or workplace and financial stressors.
3. “Wellness” means a broad approach for things individuals can do at their own pace, in their own time, and within their own abilities, which can help them feel better and live longer.

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.

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2. Ohio Legislative Service Commission. Ohio Laws and Administrative Rule 5122-29-15.1: Adult, Family, and Youth Certified Peer Supporter. https://codes.ohio.gov/ohio-administrative-code/rule-5122-29-15.1. Published April 8, 2022. Accessed July 7, 2025.
3. Ohio Legislative Service Commission. Ohio Laws and Administrative Rule 5160-27-02: Coverage and limitations of behavioral health services. https://codes.ohio.gov/ohio-administrative-code/rule-5160-27-02. Published March 24, 2024. Accessed July 7, 2025.
4. Ohio Legislative Service Commission. Ohio Laws and Administrative Rule 5160-27-04: Mental health assertive community treatment service. https://codes.ohio.gov/ohio-administrative-code/rule-5160-27-04. Published January 1, 2021. Accessed July 7, 2025.
5. Ohio Legislative Service Commission. Ohio Laws and Administrative Rule 5160-27-09: substance use disorder treatment services. https://codes.ohio.gov/ohio-administrative-code/rule-5160-27-09. Published January 1, 2018. Accessed July 7, 2025.
6. Ohio Legislative Service Commission. Ohio Laws and Administrative Rule 5122-29-28: Intensive home-based treatment (IHBT) service. https://codes.ohio.gov/ohio-administrative-code/rule-5122-29-28. Published March 1, 2022. Accessed July 7, 2025.
7. Ohio Legislative Service Commission. Ohio Laws and Administrative Rule: 5122-29-14: Mobile response and stabilization service. https://codes.ohio.gov/ohio-administrative-code/rule-5122-29-14. Published April 1, 2025. Accessed July 7, 2025

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; 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 or guarantee regarding 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 are strictly prohibited. Providers, members/enrollees, and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where 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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