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Ohio Department of Medicaid Utilization Management Changes Effective July 1, 2026

The Ohio Department of Medicaid (ODM) recently issued a bulletin announcing new utilization management (UM) requirements for certain community behavioral health services effective July 1, 2026. ODM states the changes are being implemented in response to a “sustained and statistically significant increase” in utilization of behavioral health services across Medicaid populations and intended to standardize authorization thresholds and oversight practices, preserve medical necessity review at key intervals, and ensure appropriate, intentional and personalized care for members.

Prospective Utilization Controls

Historically, many community behavioral health services could be rendered without substantial utilization oversight until retrospective audit activity occurred. Effective July 1, 2026, ODM is moving toward prospective utilization controls through predetermined service thresholds and authorization checkpoints.  The new ODM-approved UM policies establish service utilization thresholds after which prior authorization will be required for continued reimbursement for specified community behavioral health and SUD services. The authorizations will be implemented as “pass throughs,” which means that an approved authorization will not be required to initiate a service.   If the service limit is reached within the calendar year, an authorization will be required to continue services.   

Services Subject to Prior Authorization 

The services that are subject to the new prior authorization requirements, their corresponding thresholds and MCO turnaround times include the following:

Several of the UM changes also establish combined daily unit limitations when certain behavioral health services are furnished on the same date of service.

ODM emphasized services will continue to be covered when medically necessary, but providers may need to submit additional clinical documentation to justify continued or higher-frequency treatment beyond the established limits.

What Should Providers Do?

Providers should expect increased concurrent review activity and greater scrutiny of medical necessity documentation for extended or high-frequency services.  Providers are encouraged to monitor service utilization throughout the course of treatment to avoid interruptions in care.  Further, Providers should continue to coordinate care when members are receiving services from multiple agencies to prevent duplication of services and premature exhaustion of authorized units. 

ODM and participating MCOs are expected to require stronger documentation supporting medical necessity, frequency and duration of services, treatment progress, individualized treatment planning, and clinical justification for services exceeding established thresholds.  Additionally, providers should anticipate a greater emphasis on contemporaneous documentation and measurable clinical outcomes. Providers participating with multiple Ohio Medicaid MCOs should closely monitor plan bulletins and provider manuals to identify any operational differences.

Behavioral health providers in Ohio who participate in Ohio Medicaid should proactively evaluate operational readiness, documentation sufficiency and payer-specific authorization requirements in advance of implementation to reduce disruption and mitigate enforcement exposure.

Should you have any questions regarding these new requirements, please contact Ms. Rubin. 

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Disclaimer: This alert has been prepared by Eastman & Smith Ltd. for informational purposes only and should not be considered legal advice. This information is not intended to create, and receipt of it does not constitute, an attorney/client relationship.

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