Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-27 - Community Mental Health Agency Services
Section 5160-27-14 - Behavioral health peer support service
Universal Citation: OH Admin Code 5160-27-14
Current through all regulations passed and filed through September 16, 2024
(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.
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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