Ohio department of mental health community mental health medicaid benefits
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Ohio Department of Mental Health Community Mental Health Medicaid Benefits PowerPoint PPT Presentation


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Ohio Department of Mental Health Community Mental Health Medicaid Benefits. Kathy Cluggish. Mental Health Medicaid Benefits. The statewide Medicaid service limits will be implemented on Nov. 1, 2011. The service limits will not be pro-rated. The limits apply across providers/board areas.

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Ohio Department of Mental Health Community Mental Health Medicaid Benefits

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Ohio department of mental health community mental health medicaid benefits

Ohio Department of Mental HealthCommunity Mental Health Medicaid Benefits

Kathy Cluggish


Mental health medicaid benefits

Mental Health Medicaid Benefits

  • The statewide Medicaid service limits will be implemented on Nov. 1, 2011.

    • The service limits will not be pro-rated.

  • The limits apply across providers/board areas.

  • The service limits will be:

    • 104 hours (416 units) of CPST (H0036) per fiscal year.

    • 24 hours (24 units) of Pharmacologic Management (90862) per fiscal year .

    • 52 hours (208 units) of Individual/Group Counseling (H0004) per fiscal year.

    • 2 hours (2 units) of Diagnostic Assessment (90801) by a physician per fiscal year.

    • 4 hours (4 units) of Diagnostic Assessment by a non-physician (H0031) per fiscal year.

    • 60 days of Partial Hospitalization (S0201) per fiscal year.

      • Children can receive 2-units of partial hospitalization per day; adults can receive 1-unit per day.


Mental health medicaid benefits1

Mental Health Medicaid Benefits

  • A “soft authorization” can be used to bypass the service limits for all services to children (except partial hospitalization and CPST).

  • The “soft” authorization is implemented by putting the modifier code “SC” in the modifier 3 position on the 837P claim line.

  • The “SC” modifier can be used for children to bypass the service limits for:

    • 90862 – Pharmacologic Management

    • H0004 – Counseling

    • H0031 and 90801 – Assessment


Mental health medicaid benefits2

Mental Health Medicaid Benefits

  • Partial hospitalization (S0201) and CPST (H0036):

    • For both children and adults, a prior authorization will be required to allow additional services.

    • For children meeting the criteria set forth in Section 309.30.55 of the budget bill, a “soft authorization” can be used to bypass the need for a prior authorization for partial hospitalization and CPST.

    • The “soft” authorization is implemented by putting the modifier code “TJ” in the modifier 3 position on the 837P claim line.


Budget bill language

Budget Bill Language

SECTION 309.30.55. PRIOR AUTHORIZATION FOR COMMUNITY MENTAL HEALTH SERVICES

(A) As used in this section, "community mental health services" means mental health services included in the state Medicaid plan pursuant to section 5111.023 of the Revised Code.

(B) For fiscal year 2012 and fiscal year 2013, a Medicaid recipient who is under twenty-one years of age automatically satisfies all requirements for any prior authorization process for community mental health services provided under a component of the Medicaid program administered by the Department of Mental Health pursuant to an interagency agreement authorized by section 5111.91 of the Revised Code if any of the following apply to the recipient:

(1) The recipient is in the temporary custody or permanent custody of a public children services agency or private child placing agency or is in a planned permanent living arrangement.

(2) The recipient has been placed in protective supervision by a juvenile court.

(3) The recipient has been committed to the Department of Youth Services.

(4) The recipient is an alleged or adjudicated delinquent or unruly child receiving services under the Felony Delinquent Care and Custody Program operated under section 5139.43 of the Revised Code.


Mental health medicaid benefits3

Mental Health Medicaid Benefits

  • Misc. information:

    • There is no prior authorization or modifier for bypassing limits on Pharm. Mgmt., Counseling, or Assessment for adults.

    • There are two fields on the 837P (v4010/v5010) that need completed when submitting a claim that has been prior authorized:

      • Loop 2300, segment REF01 – must be valued with G1

      • Loop 2300, segment REF02 – prior authorization number assigned Health Care Excel

    • The benefit year for FY12 is 11/1/2011 to 6/30/2012.

      • FY13 benefit year is 7/1/2012 to 6/30/2013.

    • Annual benefit limits apply to Medicaid services only.

      • Services provided during a client’s spenddown period will not count toward the annual service limit. These claims are processed as non-Medicaid claims.

      • Crossover claims do not count toward the annual service limit. These claims are not billed to MACSIS.

      • Claims for dually eligible clients do not count toward the annual service limit; these are paid through ODJFS.

      • The annual benefit limits do not apply to other Medicaid benefits administered by ODJFS either as fee-for-service or under a managed care arrangement.


Mental health medicaid benefits4

Mental Health Medicaid Benefits

  • Misc. information (cont’d):

    • The “soft” authorization is only available for services to children and allows Ohio to comply with Early, Periodic, Screening, Diagnosis and Treatment (EPSDT), a federal provision that requires extra Medicaid services be provided to children, including preventative services. There is no similar federal provision for adults.

    • The Counseling limit includes both individual and group. This gives the provider the flexibility of providing the appropriate counseling service to the client.

    • The date of service determines which fiscal year the claim falls within.

    • Partial hospitalization is based on calendar days; they do not need to be consecutive days.

    • Using the “SC” or “TJ” modifier on a non-Medicaid claim will cause the claim to deny.

    • Using the “SC” or “TJ” modifier prior to a client’s benefit being exhausted, will have no adverse affect on the pricing/adjudication of the claim (it will not deny).

    • All of the Medicaid Cost Containment FAQs can be accessed at: http://www.mh.state.oh.us/what-we-do/protect-and-monitor/medicaid/index.shtml


Resource list

Resource List

  • ODMH MACSIS Support Desk: [email protected]

  • ODMH MACSIS Web link: http://www.mh.state.oh.us/what-we-do/protect-and-monitor/macsis/

  • ODMH Medicaid Mailbox: [email protected]

  • ODMH Medicaid Web link: http://www.mh.state.oh.us/what-we-do/protect-and-monitor/medicaid/index.shtml

  • ODJFS MITS Web portal link: https://portal.ohmits.com/public/Providers/tabid/43/Default.aspx

  • ODJFS Medicaid Consumer Hotline: 1-800-324-8680


Contact information

Contact Information:

Kathy Cluggish

MACSIS Support Desk Supervisor

ODMH Office of Health Integration

E-mail: [email protected]

(614) 466-1498


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