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This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and universities.

Rule 5160-2-76 | Outpatient hospital behavioral health services.

 

(A) For purposes of this rule, the following definitions apply:

(1) "Behavioral health (BH) services" are mental health and substance use disorder services.

(2) "Outpatient claims" are as defined in rule 5160-2-75 of the Administrative Code.

(3) "Outpatient hospital behavioral health (OPHBH) services" are mental health and substance use disorder services provided in an eligible outpatient hospital setting.

(4) "Outpatient invoice" is as defined in rule 5160-2-75 of the Administrative Code.

(5) "Procedure codes" are as defined in rule 5160-2-75 of the Administrative Code.

(B) Hospitals electing to provide and bill OPHBH services, are expected to meet the following:

(1) Medicare conditions of participation;

(2) Accreditation by a national accrediting body; and

(3) Accreditation for the BH services they provide.

(C) Each outpatient claim for BH should contain the following:

(1) Modifier 'HE' at the detail level for each BH current procedural terminology/healthcare common procedure coding system code;

(2) Revenue center code 0671, 0900, 0901, 0904, 0906, 0907, 0911, 0912, 0913, 0914, 0915, 0916, 0918, 0919 or 1002 for each BH detail line; and

(3) A BH diagnosis code.

(D) Payments for BH services will be paid the lesser of charges or in accordance with the OPHBH fee schedule in effect on the date of services rendered. The OPHBH fee schedule is published on the department's website, http://medicaid.ohio.gov/.

(E) Notwithstanding paragraph (B)(2) of rule 5160-2-02 of the Administrative Code, BH services reimbursed under this paragraph are excluded from inpatient services.

(F) Payment under this rule is inclusive of both professional and facility reimbursement.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02, 5164.70
Five Year Review Date: 11/15/2025