POLICY AND PROCEDURE

POLICY STATEMENT:

To ensure appropriate utilization, prevent duplication of services, and maintain program integrity within the Ohio Medicaid behavioral health benefit, this policy establishes limits on billing multiple rehabilitative behavioral health services for the same member on the same date of service.

PURPOSE:

This policy applies to all contracted behavioral health providers and provider types delivering rehabilitative behavioral health services under the Ohio Medicaid Managed Care benefit, including but not limited to community mental health centers (provider type 84 and 95), and independent practitioners.

SCOPE:

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

POLICY:

Background:

Behavioral Health Rehabilitative Services: Services that are structured, goal-directed interventions that support recovery, promote skill-building, and reduce the need for higher levels of care. They are typically non-physician, non-therapy services provided by qualified behavioral health practitioners under a treatment plan. They are designed to restore or enhance an individual’s functioning and ability to live independently, including but not limited to Psychosocial Rehabilitation (PSR), and Therapeutic Behavioral Services (TBS).

Multiple/ Duplicative Services: Services that overlap in purpose, time, or clinical intent, and do not represent distinct, medically necessary interventions.

Types of Behavioral Health Rehabilitative Services:

Psychosocial Rehabilitation (PSR H2017) Services

• Purpose: Help individuals develop or restore social and daily living skills to improve community functioning.
• Examples:
  • Building coping, communication, or problem-solving skills
  • Improving self-care, money management, or medication adherence
  • Practicing social or vocational skills
• Staff: Qualified behavioral health specialists or paraprofessionals under supervision

Therapeutic Behavioral Services (TBS H2020 and H2019)

• Purpose: Provide individualized, intensive behavioral interventions to reduce symptoms and improve functioning, often for children and youth.
• Examples:
  • Skill development for managing anger or anxiety
  • Behavioral coaching in the home or community
  • Crisis prevention planning
• Staff: Qualified mental health specialists or case managers trained in behavioral interventions

Community Psychiatric Supportive Treatment (CPST H0036)

• Purpose: Assist individuals with achieving treatment goals and improving stability through ongoing community-based support.
• Examples:
  • Coordinating services and supports
  • Developing coping and daily living skills
  • Providing education on mental health or substance use management
• Staff: Qualified mental health specialists under supervision

Disallowance Of Multiple/ Duplicative Services:

Unit based (non-per diem) rehabilitative behavioral health services—including but not limited to Community Psychiatric Supportive Treatment (CPST H0036), Therapeutic Behavioral Services (TBS H2019), and Psychosocial Rehabilitation (PSR H2017) shall not be reimbursed when more than 16 units of any combination of services is rendered to the same member by the same or different provider organizations on the same date of service, unless specifically authorized under an approved treatment plan and clinically justified.

1. Clinical Exception: Multiple rehabilitative services may be allowed on the same date of service only when:
   • The services are distinct in purpose and function (e.g., CPST addressing symptom management and PSR addressing skill development);
   • The documentation clearly supports separate and non-overlapping service delivery, time, and intervention goals; and
   • The combined service duration does not exceed reasonable daily limits or clinical necessity as determined by the plan’s utilization management criteria.

3. Claims Processing:
   • Claims submitted for multiple rehabilitative services for the same member, same date of service, and same billing provider (or related providers under common ownership) will be subject to claim denial or post-payment review.

Overlapping Rehabilitative Services with Per Diem Services:

Buckeye shall limit reimbursement for behavioral health rehabilitative services to a maximum of four (4) units per member per date of service when such services are rendered on the same date as a per diem Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), or Therapeutic Behavioral Services (H2020). This limitation supports appropriate clinical integration and ensures that rehabilitative services do not overlap with the intensive treatment structure already included in the per diem IOP (H0015), PHP (H0015 TG), or TBS (H2020) rate.

Rehabilitative services are not separately reimbursable when Substance Use Disorder (SUD) Residential Treatment Center (RTC 2036, H2034) and Withdrawal Management Services (H0010-14) are billed on same day and will be denied.

Prior Authorization Process:

If a provider submits a claim for services that exceed the amounts referenced above without a prior authorization:

1. Buckeye will deny the claim; and

2. If the provider does not submit the medical records and documentation requested within 30 days of the request, the claim will remain denied.
3. 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).
4. 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.

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.

OAC 5160-27-04: Intensive Outpatient and Partial Hospitalization Services
OAC 5160-27-05: Rehabilitative Services
ODM Behavioral Health Coding and Reimbursement Manual
Managed Care Provider Agreement, Attachment F: Behavioral Health 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.