Ohio Behavioral Health Credentialing: ODM Enrollment, OhioRISE and OhioMHAS Rules Explained

How Ohio splits behavioral health billing

The Ohio Department of Medicaid (ODM) organizes its behavioral health guidance into two groups. One is community behavioral health providers certified by the Ohio Department of Mental Health and Addiction Services (OhioMHAS), covered by OAC Chapter 5160-27. The other is independent providers who are not certified by OhioMHAS, covered by OAC rule 5160-8-05.

OhioMHAS-certified agencies

The first track is built around the agency. An entity that meets the certification requirements in Revised Code 5119.36 and OAC Chapters 5122-24 through 5122-29 can enroll as a Medicaid provider. Its licensed practitioners render services as employees or independent contractors.

ODM's behavioral health manual puts certification first. Once an agency holds it, the agency applies for provider type 84 to bill the mental health benefit, provider type 95 for the substance use disorder benefit, or both. A specialty must be selected for each type, and an application fee may apply.

Independent practitioners

The second track is built around the clinician. Rule 5160-8-05 is titled "Behavioral health services-other licensed professionals." It lets Medicaid pay physician group practices, clinics, community behavioral health centers, physicians, advanced practice registered nurses, physician assistants, licensed psychologists in independent practice and independent practitioners in independent practice.

The independent-level licenses named in the related rules include licensed independent social workers (LISW), licensed professional clinical counselors (LPCC), licensed independent marriage and family therapists (LIMFT) and licensed independent chemical dependency counselors (LICDC). Ohio does not use the LCSW title, so a social worker billing independently is an LISW.

Supervised practitioners and trainees

The same rule covers supervised practitioners and trainees. A supervising entity or independent practice can bill for their services, but only when the supervision conditions in the rule are met.

Which track fits a practice

A practice that straddles both worlds is where problems start. A group that employs LPCCs and LISWs, offers agency-level services such as case management and holds no OhioMHAS certification cannot bill those services under an independent enrollment.

The reverse happens too. A certified agency that adds an independent clinician has to decide whether that person bills under the agency or as a separate provider. The answer changes whose NPI appears on the claim.

The credentialing process, step by step

Ohio centralized provider enrollment and credentialing in the Provider Network Management (PNM) module. ODM calls it the single point for enrollment, credentialing and provider self-service. ODM screens and credentials providers under federal rules (42 CFR 455, subpart E), so the managed care plans and OhioRISE do not run a second credentialing process for behavioral health providers.

Aetna's OhioRISE provider manual says the same thing: credentialing happens through ODM and not through Aetna. The process below follows that structure.

Step 1: Pick the track and gather documents

Decide first whether the practice is an OhioMHAS-certified agency, an independent practice or both. Agencies need their OhioMHAS certification in hand before applying. Independent clinicians need an active license at the independent level, an NPI, a tax ID, a practice location and ownership disclosures where they apply.

Step 2: Apply in PNM

All enrollment applications go through PNM. The applicant selects a provider type and then a specialty. Agencies choose type 84, 95 or both, and the fee that applies to those types gets paid at this stage. Picking the wrong type here is the most common source of denials later.

Step 3: ODM screening and credentialing

ODM screens the application and credentials the provider. One credentialing record covers Medicaid, OhioRISE and MyCare. Turnaround varies, so a practice should start well before its first scheduled visit and avoid booking Medicaid patients on the assumption of a fixed approval date.

Step 4: Check the Medicaid provider record

Once approved, the provider receives an Ohio Medicaid provider ID. The next job is reading the record line by line: license, taxonomy, address, group affiliation and specialties. A typo here follows every claim.

Step 5: Contract with each plan

Credentialing does not place a provider in a plan's network. A practice signs a contract with each Medicaid managed care plan it wants to bill, plus Aetna Better Health of Ohio if it will see OhioRISE members. The plans check the PNM record as the system of record.

Step 6: Keep the record current

Revalidation notices, new clinicians, address changes and added specialties all go through PNM. A lapsed revalidation can end an active enrollment, and a stale record can cause denials months after the change that triggered them.

Common ODM enrollment mistakes

Several enrollment errors repeat across practices:

• Enrolling under the wrong provider type for the service being billed
• Missing a specialty that a program requires, including OhioRISE specialties
• Leaving old addresses or group affiliations in PNM after a move or staffing change
• Skipping revalidation notices
• Entering a multi-license clinician under one credential only

Multi-license clinicians

The last item needs its own note. ODM's behavioral health manual says practitioner modifiers are optional unless a practitioner holds more than one license, and in that case ODM's dual licensure grid applies.

A clinician who is both a licensed social worker and a chemical dependency counselor, for example, needs an enrollment and a claim that agree on which license covers the service.

Seven managed care plans, one credentialing record

Most Medicaid members receive care through managed care. ODM lists seven plans: AmeriHealth Caritas Ohio, Anthem Blue Cross and Blue Shield, Buckeye Community Health Plan, CareSource Ohio, Humana Healthy Horizons in Ohio, Molina Healthcare of Ohio and UnitedHealthcare Community Plan of Ohio.

Contracting is separate

Each plan has its own claims portal, authorization rules and appeal process. Practices with a small caseload often contract with two or three plans, then find new patients arriving on the others. The first denial of that kind reads like a network problem, and the cause is usually a contract that was never signed.

Fee-for-service members

Some Medicaid members, such as those in fee-for-service categories, bill through ODM directly. An eligibility check at the start of each month catches those cases before the first session.

OhioRISE: a separate plan for youth with complex needs

OhioRISE is a specialized managed care program for youth with complex behavioral health and multi-system needs. ODM selected Aetna Better Health of Ohio to run it, and ODM determines eligibility using a Child and Adolescent Needs and Strengths (CANS) assessment.

Most children covered by Medicaid stay in their regular managed care plan. A pediatric caseload can therefore include both kinds of members at once.

What providers need

Two rules matter. ODM requires providers to add the right specialty to an existing enrollment type to bill some new and enhanced OhioRISE services, and behavioral health respite is one example. Providers must also contract with Aetna to serve OhioRISE members. ODM enrollment alone does not put a therapist in the OhioRISE network.

How to credential with OhioRISE as a therapist

1. Confirm active Ohio Medicaid enrollment in PNM, or apply if the practice has none.
2. Add the OhioRISE specialty in PNM if the services require one.
3. Complete ODM's centralized credentialing, which covers OhioRISE, Medicaid and MyCare.
4. Contract with Aetna Better Health of Ohio for OhioRISE through its network team.
5. Check each member's OhioRISE enrollment before a session, and match modifiers to ODM's dual licensure grid when a clinician holds two licenses.

When a child changes plans

Step five catches many practices. A child can move into or out of OhioRISE as needs change, which means the payer for the same patient can change between visits.

Where the denials come from

Most denials trace back to a mismatch among three records: the PNM enrollment, the payer contract and the claim. A short list covers the usual causes.

• A provider type or specialty that does not match the service billed
• A billing or rendering NPI that differs from the PNM record
• No contract with the plan that pays for the member, whether a standard managed care plan or OhioRISE
• A missing or wrong modifier for a dually licensed clinician
• A claim sent to the wrong plan after a member changed coverage
• Filing past the deadline

The filing deadline

Under OAC rule 5160-1-19, Medicaid claims are timely when ODM receives them within 365 days of the date of service, with exceptions listed in the rule, such as claims that follow a third-party payment reversal. ODM does not accept paper claims unless it directs otherwise.

Disputes follow separate routes. Fee-for-service claims use ODM's Medical Claim Review Request, and managed care claims go through the plan's own appeal process.

A short checklist before the first claim

1. Decide whether the practice is OhioMHAS-certified, independent or both, and enroll under the matching rule.
2. Check the PNM record for license, taxonomy, address, group affiliation and specialties.
3. Contract with each Medicaid plan the practice intends to bill, plus Aetna for OhioRISE where it applies.
4. Record which clinicians hold more than one license and apply the dual licensure grid.
5. Verify member eligibility and plan at the start of each month, and again for youth who may move into OhioRISE.
6. Calendar the revalidation date for every provider and track the 365-day filing limit on open claims.

Where billing support fits

Frequently asked questions