Ohio Billing Guide for Mental Health Therapists and Psychiatrists
Who pays, where to enroll and which rules change your claims in Ohio, for psychotherapists and psychiatric prescribers.
Last checked October 25, 2026. Reviewed against the official sources listed at the bottom of this page.
This Ohio billing guide covers Medicaid, Medicare, Blue Cross, other private payers and state law for therapists and psychiatrists, with sources and a last-checked date.
Ohio billing guide: how Ohio pays for outpatient care
Ohio Medicaid is run by the Ohio Department of Medicaid (ODM). Most members are in Next Generation managed care through seven managed care organizations, so you bill the member's plan. One enrollment in the Provider Network Management (PNM) system covers contracting with any Ohio Medicaid plan.
Youth with complex behavioral health needs are served through OhioRISE, a separate program managed by Aetna Better Health of Ohio. Community behavioral health services are governed by Ohio Administrative Code Chapter 5160-27.
Who to bill, at a glance
| Payer type | Who you bill | Where to enroll or check rules |
|---|---|---|
| Medicaid | Ohio Department of Medicaid; seven Next Generation plans; PNM for enrollment | Ohio Department of Medicaid |
| Medicare Part B | CGS Administrators, Jurisdiction 15 | CMS MAC page |
| Blue Cross Blue Shield | Anthem Blue Cross and Blue Shield (Elevance Health) | See the Blue Cross section below |
Ohio Medicaid: Ohio Medicaid Next Generation
This Ohio billing guide starts with Medicaid, because it decides who pays and how you file.
Seven Next Generation managed care organizations began serving members on February 1, 2023. Fee-for-service continues for some members. Providers choose which plans to contract with, and one PNM enrollment and credentialing application covers contracting with any Ohio Medicaid plan.
No statewide behavioral health carve-out turned up in ODM's program overview or managed care FAQ. Behavioral health is covered through the plans under Chapter 5160-27, and youth with complex needs are in OhioRISE.
| Item | What to know |
|---|---|
| Agency | Ohio Department of Medicaid |
| Behavioral health rules | Ohio Administrative Code Chapter 5160-27 |
| Provider Network Management | ODM requires providers serving managed care, OhioRISE or pharmacy benefit manager members to be enrolled and active in PNM. Otherwise claims can reject with CARC 226 and RARC N767. Temporary enrollment lasts 120 days. Summary of the ODM notice |
| Fee-for-service filing window | Claims are timely if ODM receives them within 365 days of the date of service. Managed care plans set their own deadlines. OAC 5160-1-19 |
| Managed care FAQ | ODM Medicaid managed care FAQ |
| Work requirement | An ODM February 2026 presentation says the community engagement requirement is scheduled to begin January 1, 2027 for expansion adults, with six-month redeterminations. Source |
Managed-care plans and carve-outs
| Plan or entity | Role in behavioral health |
|---|---|
| AmeriHealth Caritas Ohio | Next Generation plan listed in the ODM FAQ. |
| Anthem Blue Cross and Blue Shield | Next Generation plan; Carelon Behavioral Health provides utilization management for Ohio Medicaid. |
| Buckeye Health Plan | Next Generation plan. Not open to new NextGen MyCare members for plan year 2026. |
| CareSource Ohio | Next Generation plan and a NextGen MyCare plan. |
| Humana Healthy Horizons in Ohio | Next Generation plan listed in the ODM FAQ. |
| Molina Healthcare of Ohio | Next Generation plan and a NextGen MyCare plan. |
| UnitedHealthcare Community Plan of Ohio | Next Generation plan listed in the ODM FAQ. |
Check the ODM managed care FAQ for the current plan list before you contract.
Medicare Part B in Ohio
For Medicare, this Ohio billing guide names your contractor and the current telehealth rules.
Medicare Part B pays for outpatient psychotherapy and psychiatric visits billed to the Medicare Administrative Contractor (MAC) for your state. CMS's July 14, 2026 fact sheet on the CY2027 Physician Fee Schedule proposed rule says the Consolidated Appropriations Act, 2026 extended telehealth payment authority through December 31, 2027, and proposes that in-person visit requirements for mental health visits not apply to services furnished through that date.
| Item | What to know |
|---|---|
| Contractor | CGS Administrators, LLC |
| Jurisdiction | Jurisdiction 15: Kentucky and Ohio |
| Source | CMS.gov MAC page |
Blue Cross Blue Shield in Ohio
This part of the Ohio billing guide names the exact Blue Cross licensee, because Blue plans never share rules.
Blue Cross Blue Shield is a federation of independent companies, so one licensee's rules never apply to another. In Ohio that is Anthem Blue Cross and Blue Shield, owned by Elevance Health. Elevance's 10-Q for the quarter ended March 31, 2026 lists Ohio among its Blue licensee states. Its rules do not apply to Blue plans in other states.
| Licensee | Parent or affiliation | Where it applies | Provider resources |
|---|---|---|---|
| Anthem Blue Cross and Blue Shield (Ohio) | Elevance Health, Inc. | Ohio | Anthem Ohio behavioral health |
Other private payers and EAPs in Ohio
The Ohio billing guide also covers commercial plans and employee assistance programs.
These commercial payers and plan families most often matter for behavioral health billing in Ohio. Check each payer's current provider manual before you submit.
| Payer | Behavioral health note | Provider resources |
|---|---|---|
| Anthem Blue Cross and Blue Shield | The Anthem Ohio behavioral health page describes behavioral health services and virtual outpatient care. Carelon Behavioral Health provides utilization management for Anthem Ohio Medicaid. | Official page |
| Carelon Behavioral Health | Carelon is an independent company that provides utilization management for Anthem. Its quick reference says claim disputes are due within 12 months of the date of service or 60 days after payment or denial, whichever is later. | Official page |
| Cigna / Evernorth Behavioral Health | The Evernorth administrative guide prefers electronic claims and says EAP claims must use CPT 99404. | Official page |
Ohio billing guide: state law that changes billing
Use this section of the Ohio billing guide to separate state law from payer policy.
State law sets the floor for commercial plans in Ohio. Medicare and Medicaid rules are covered in their own sections above.
Mental health parity
Ohio Revised Code 1751.01, 3923.28, 3923.281 and 3923.282 work alongside federal parity law. The Ohio Department of Insurance says copays, deductibles, out-of-pocket maximums and treatment limits cannot be more restrictive for mental health or substance use than for medical and surgical benefits. ODI parity report
Telehealth coverage
ORC 3902.30 requires health benefit plans to cover telehealth on the same basis as in-person care, with no higher cost sharing. It does not require payment parity or a specific reimbursement amount. Statute
Prompt payment
ORC 3901.381 requires third-party payers to pay or deny a standard claim within 30 days of receipt, or 45 days if additional documentation is needed. Statute
Practitioner scope: therapists
The Ohio Counselor, Social Worker, and Marriage and Family Therapist Board licenses professional counselors, social workers and marriage and family therapists. Board rules
Not legal advice. Confirm statute details with counsel.
Ohio billing guide: codes and rates
This Ohio billing guide lists only codes and rates confirmed on official pages.
These are the Ohio-specific codes, modifiers and rate items confirmed on official pages. Medicare's own CY2027 conversion factor proposal is listed under What changed.
| Code or item | What to know |
|---|---|
| Community behavioral health fee schedule | Rates are in the appendix to rule 5160-27-03. Check the appendix for current amounts. Source |
| Telehealth | Rule 5160-27-02 addresses telehealth for community behavioral health. Confirm modifiers and place of service with ODM. Source |
| Claim denials for missing PNM enrollment | Denials should carry CARC 226 and RARC N767, per the ODM notice summarized by UnitedHealthcare. Source |
Ohio billing guide: what changed, newest first
Check this Ohio billing guide update log before you rely on an older rule.
| Date | What changed | Source |
|---|---|---|
| 2027-01-01 | Medicaid community engagement requirement scheduled to begin for expansion adults, per ODM. | Source |
| 2026-07-14 | CMS released the CY2027 Medicare Physician Fee Schedule proposed rule: conversion factor $32.84 for non-qualifying APM participants (down 1.68%) and $33.17 for qualifying participants (down 1.19%). | Source |
| 2026-06-16 | ODM notice, summarized by UnitedHealthcare: providers must be enrolled and active in PNM or risk rejected claims. | Source |
| 2026-02-01 | ODM presented its work requirement plan. | Source |
| 2026-01-01 | NextGen MyCare began in 29 counties, with remaining regions phasing in through August 1, 2026. | Source |
How do I bill mental health claims in Ohio?
These answers come from the same sources as the rest of this Ohio billing guide.
Start with the member's payer type. For Ohio Medicaid managed care, bill the member's plan and keep your PNM enrollment active. Medicare Part B goes to CGS Administrators in Jurisdiction 15. Anthem Blue Cross and Blue Shield, owned by Elevance Health, is the Blue licensee for commercial members.
Questions about billing in Ohio
Who do I bill for Ohio Medicaid behavioral health claims?
For managed care members, bill the member's plan. One PNM enrollment covers contracting with any Ohio Medicaid plan.
What is the Ohio Medicaid timely filing limit?
For fee-for-service, 365 days from the date of service under OAC 5160-1-19. Managed care plans set their own deadlines.
Why is an Ohio Medicaid claim rejecting with CARC 226?
ODM requires providers serving managed care members to be enrolled and active in PNM. Check your PNM status.
Who is the Medicare contractor in Ohio?
CGS Administrators in Jurisdiction 15, which covers Kentucky and Ohio.
Does MCM South bill for practices in Ohio?
MCM South currently serves ten states; request a quote to ask about Ohio.
Sources for the Ohio billing guide
Last checked October 25, 2026. Every source below was opened and read on that date.
- Ohio Department of Medicaid, checked October 25, 2026
- ODM managed care FAQ, checked October 25, 2026
- Ohio Administrative Code Chapter 5160-27, checked October 25, 2026
- Ohio Administrative Code 5160-1-19, checked October 25, 2026
- ODM work requirements presentation, February 2026, checked October 25, 2026
- UnitedHealthcare summary of the ODM PNM notice, checked October 25, 2026
- CMS: MAC Jurisdiction 15, checked October 25, 2026
- Anthem Ohio behavioral health, checked October 25, 2026
- Carelon Ohio quick reference, checked October 25, 2026
- Evernorth administrative guide, checked October 25, 2026
- Ohio Revised Code 3902.30, checked October 25, 2026
- Ohio Revised Code 3901.381, checked October 25, 2026
- Ohio Department of Insurance parity report, checked October 25, 2026
- CMS: CY2027 Physician Fee Schedule proposed rule fact sheet, checked October 25, 2026
- CMS MAC jurisdiction page, checked October 25, 2026
Related guides
- State & Regional Billing Guides hub
- In-network vs out-of-network credentialing
- Credentialing and network status
- Blue Cross Blue Shield guide for Ohio
- Mental health parity explained
- Medicaid managed care billing
- Medicare behavioral health billing
- Timely filing in the billing glossary
- Who we serve
- Illinois insurance companies contact guide
- Tennessee insurance companies contact guide
Billing in Ohio? Let us handle the payer calls.
MCM South bills only mental and behavioral health, for psychotherapists and psychiatrists, in solo and medium-size practices. We currently serve ten states; request a quote to ask about Ohio.
MCM South currently serves practices in ten states: Georgia, Massachusetts, Connecticut, Texas, Florida, New York, Colorado, Tennessee, North Carolina and Illinois.