ODM Releases New Process for Requesting Prior Authorization for PRTF

ODM released a new memo to update providers about the new process for PRTF referral and authorization. Ohio’s child-serving agencies have worked closely with the OhioRISE plan and Aetna Better Health of Ohio to bring Psychiatric Residential Treatment Facility (PRTF) services to Ohio, extending the continuum of care for children/youth with the most intensive behavioral health needs. Beginning November 1^st, 2023, Medicaid coverage of PRTF treatment will require the OhioRISE care coordinator to submit a PRTF Request Form to Aetna for both in-state and out-of-state PRTF services.

For Medicaid to cover PRTF services that are deemed medically necessary, the child/youth must be qualified for and enrolled in OhioRISE. Connection to OhioRISE enrollment is through an Ohio Children’s Initiative Child and Adolescent Needs and Strengths (CANS) assessment. As of November 1^st, 2023, for Aetna to cover PRTF Treatment, the OhioRISE care coordinator at the OhioRISE care management entity (CME) or Aetna will complete the PRTF Request form in Aetna’s PRTF Request Portal. For reference, the information collected in the portal is in Appendix B in the OhioRISE PRTF Program Manual. If Aetna determines that PRTF treatment is medically necessary for a child/youth, Aetna will refer the child/youth to a PRTF provider.

A PRTF Request Form will not be required for youth who are already receiving treatment in PRTF facilities out-of-state or for whom Aetna has already authorized PRTF treatment. If a child is not yet enrolled in OhioRISE but is identified as potentially needing PRTF treatment, the agency should reach out immediately to a CME, Aetna, or the child’s Managed Care Organization to obtain a CANS assessment and OhioRISE enrollment determination. Contact for each CME can be found here.

Please carefully review the ODM Memo for the PRTF Referral and Authorization Process, and direct any questions on this matter to OhioRISE at [email protected].