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July 2026 Top of Mind
Annual UM thresholds established for community behavioral health and SUD services beginning July 1
Effective July 1, 2026, The Ohio Department of Medicaid (ODM) implemented new utilization management (UM) service thresholds for some substance use disorder (SUD) services and community behavioral health services. The thresholds establish the amount of services that can be delivered to Medicaid members before utilization management is required.
What’s changing?
The new thresholds apply to SUD and community behavioral health services. These UM changes support appropriate medical necessity reviews at key intervals and ensure intentional and personalized care for Medicaid members.
The following services are newly subject to utilization management thresholds. Any services not outlined below will continue to be managed under existing requirements.
Service |
Service Code |
Threshold when authorization is required (per calendar year) |
SUD Intensive Outpatient Program (IOP) |
H0015 |
30 units |
Psychosocial Rehabilitation (PSR) Services |
H2017 |
200 units (50 hrs) combined TBS or PSR |
Individual Therapeutic Behavioral Service (TBS) |
H2019 |
200 units (50 hrs) combined TBS or PSR |
Group Therapeutic Behavioral Service |
H2019 HQ |
120 units (30 hrs) |
Therapeutic Behavioral Service Day Treatment – per diem |
H2020 |
After 30 units |
Community Psychiatric Support Treatment – Individual |
H0036 |
200 units (50 hrs) |
Community Psychiatric Support Treatment – Group |
H0036 HQ |
120 units (30 hrs) |
Residential Medically Managed Withdrawal Management |
H0011 |
After day 7 of treatment |
Key items to note
- Authorization is not required to initiate a service. If the threshold limit is reached within the calendar year, a medical necessity review will be required to continue services.
- To make it easier to manage these UM changes, the Optum Behavioral Health Care Engagement (OCE) team will monitor members who are receiving these services and reach out to you when a UM threshold is reached. The OCE team will attempt to reach the treating clinician or designated point of contact twice in a two-week period to conduct a medical necessity review.
Next steps
Review our Ohio UM Thresholds Quick Reference Guide for additional details about these new UM thresholds, how utilization is monitored, clinical criteria to determine medical necessity, how to submit an authorization request and more. Then, update your workflows to align with these requirements.
You may also wish to review these resources.
- The Ohio Medicaid bulletin announcing this change
- Ohio Behavioral Health Supplemental Criteria
- UnitedHealthcare utilization management policy
Questions
For assistance, please call Provider Services at 1-877-614-0484, Monday – Friday, 7 am – 7 pm CT.
