Rule 5160-27-14 | Behavioral health peer support service.
(A) For the purposes of this rule, behavioral health peer support service is the service as set forth by the Ohio department of mental health and addiction services (OhioMHAS) in rule 5122-29-15 of the Administrative Code.
(B) Eligible providers.
(1) An eligible rendering provider of peer support services is:
(a) A person who is eligible to provide peer support services in accordance with rule 5122-29-15.1 of the Administrative Code; and
(b) An eligible provider of behavioral health services in accordance with rule 5160-27-01 of the Administrative Code.
(2) An eligible billing provider is:
(a) An eligible behavioral health provider that meets the conditions in paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code; and
(b) Employs or contracts with an eligible rendering provider of peer support services as described in this rule.
(C) Coverage.
(1) The peer support service is covered when:
(a) Provided in accordance with the activities as described in rule 5122-29-15 of the Administrative Code.
(b) Rendered as a component of behavioral health treatment for the purpose of addressing the individual's behavioral health care needs relating to a mental health or substance use disorder.
(c) Intended to achieve goals or objectives based on and documented in a current individualized treatment plan meeting the requirements in rule 5122-27-03 of the Administrative Code.
(D) Limitations.
(1) The peer recovery service has to be prior authorized when rendered for more than four hours to the same individual on the same date of service.
(2) Transportation activities that do not include the provision of a peer support service are not covered.
(3) Provision of a peer support service is reimbursed in accordance with this rule and may not be reimbursed as another covered medicaid service, including, but not limited to, the following:
(a) Community psychiatric supportive treatment.
(b) Therapeutic behavioral services.
(c) Psychosocial rehabilitation.
(d) Substance use disorder target case management.
(4) Payment is not allowable when a peer support service is provided in a group setting and the certified peer supporter to client ratio exceeds one to twelve.
(5) When peer support service is delivered to caregivers or family members of the individual, it is reimburseable when the purpose of the service is to address the behavioral health needs, goals, and objectives as documented in the individual's treatment plan.
(E) Reimbursement.
(1) The medicaid reimbursement rate for the peer support service is stated in the appendix to rule 5160-27-03 of the Administrative Code. The peer support service is not reimbursable when covered as part of another medicaid reimbursable service. Reimbursement will not be made for peer support services when an individual is:
(a) Receiving intensive home-based treatment as described in rule 5122-29-28 of the Administrative Code.
(b) Receiving assertive community treatment as described in rule 5160-27-04 of the Administrative Code.
(c) Receiving mobile response and stabilization service as described in rule 5160-27-13 of the Administrative Code.
(d) Receiving substance use disorder residential treatment services as described in rule 5160-27-09 of the Administrative Code, except when the peer support service is necessary to support admission to and discharge from the substance use disorder residential treatment. Payment for the services provided during a substance use disorder residential treatment stay is made in accordance with rule 5160-27-09 of the Administrative Code.
(e) Receiving inpatient hospital psychiatric services as described in Chapter 5160-2 of the Administrative Code, except when the peer support service is necessary to support admission to and discharge from the hospital. Payment for the services provided during an inpatient hospital stay is made in accordance with Chapter 5160-2 of the Administrative Code.
(f) Receiving psychiatric residential treatment facility (PRTF) services as described in Chapter 5122-41 of the Administrative Code and rule 5160-59-03.6 of the Administrative Code, except when the peer support service is necessary to support admission to and discharge from the PRTF. Payment for the services provided during a PRTF stay is made in accordance with rule 5160-59-03.6 of the Administrative Code.
Last updated September 3, 2024 at 9:09 AM
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