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Magellan updates SOR funding requirements effective March 1, 2026

Overview

SOR program – Claim diagnosis requirements
Beginning March 1, 2026, any claims submitted for SOR-funded members, regardless of the date-of-service, will be administratively denied if the primary diagnosis is not opioid- or stimulant-related.

SUPTRS program - Claim diagnosis requirements
Beginning March 1, 2026, any claims submitted for Substance Use Prevention, Treatment, and Recovery Services (SUPTRS)‑funded members, regardless of the date-of-service, will be administratively denied if they do not include a primary diagnosis of a substance use disorder, with the exception of opioids or stimulants.

Provider guidance

  • Providers are encouraged to review current billing practices to ensure that all claims submitted for SOR and SUPTRS members are billed with the appropriate primary diagnosis consistent with program funding requirements to avoid payment delays or denials.
  • SOR funding is limited to opioid or stimulant use.
    • Examples: Use of Fentanyl, oxycodone, Percocet, heroin, and amphetamines.
  • Providers must verify the type of Other State Funding (OSF), SOR or SUPTRS, for which the member has been approved and ensure the member’s diagnosis aligns with the diagnoses allowable for billing under that funding source.
    • For assistance verifying the type of OSF, please contact the Magellan Provider Line at 1-855-202-0983.

Allowable diagnoses and codes
Members covered under SOR and SUPTRS programs are authorized under their respective other state‑funded coverage based on self‑reported need for substance use treatment. Federal requirements limit the allowable diagnoses that may be billed under each program. Please review the allowable diagnosis and codes tables below.

SOR allowable diagnoses and code ranges


SUPTR allowable diagnoses and code ranges


Eligibility renewals

  • Eligibility screenings are done annually.
  • If criteria continues to be met, eligibility will be extended.

Questions?
If you have questions regarding these updates or need assistance, please contact your Magellan Provider Relations representative. If you are unsure who your provider relations representative is,
please reach out to the provider inbox at IdahoProvider@MagellanHealth.com.

Overview

This State Fiscal Year, Magellan has experienced increased utilization of Safe and Sober Housing (SSH) benefits. To preserve access to therapeutic services for the remainder of the fiscal year, effective Jan. 16, 2026, Magellan will no longer create new or extend existing SSH authorizations for State Opioid Response (SOR)-funded members.

SOR-funded members 24 and older currently utilizing SSH housing benefits must be transitioned out of these benefits by Feb. 16, 2026, and connected to other outpatient services. New and existing SOR-funded members between the ages of 18-24 can continue accessing SSH services until their 24th birthday. 

Both Magellan and Idaho’s Department of Health and Welfare recognize the impact this change may have on members and providers. We are committed to working collaboratively to support all parties throughout this transition.

Claims submission

Claims for SSH services for SOR-funded members, aged 24 and older, for dates of service on or after Feb. 16, 2026, will be denied. Please ensure SOR-funded members are transitioned by this date.

Provider guidance

Providers are encouraged to begin immediately supporting SOR OSF members, age 24 and older, in identifying alternative resources, including non-Magellan-funded community-based housing options. Idaho 211, which can help connect individuals to other essential community services.

Additional updates will be shared if and when SSH resources become available again for SOR-funded members.

Important reminder

SOR members will continue to have access to behavioral health outpatient services.

SOR members aged 18 until their 24th birthday have continued access to SSH services.

Please do not direct SOR members to contact Magellan to request a switch to SUPTRS funding. Funding determinations will continue to follow established eligibility criteria. Members currently eligible under SOR will not be screened for eligibility under any other category.

Thank you for your cooperation in ensuring accurate guidance for members.

In an effort to easily identify SOR funded members 24 and older, Magellan will provide SSH providers a list of members currently authorized for housing services at their facility. Please reach out to IdahoProvider@MagellanHealth.com for additional information.  

Questions?

Please contact Magellan at IdahoProvider@MagellanHealth.com. 

Overview
Magellan will implement changes to prior authorization rules beginning Jan. 1, 2026. These changes only apply to adult members (defined as individuals who are the age of 18 and older) with Medicaid. 

Key changes
Adult intensive outpatient services (IOP)

  • Applies to both mental health and substance use disorder (SUD) treatment.
  • A combined 50-unit annual threshold will apply.
  • Prior authorization will be required once the 50 annual combined units are used.

Adult skills-building/community-based rehabilitative services (CBRS)

  • The current 308-unit threshold will be removed.
  • Beginning Jan. 1, 2026, prior authorization will be required for all adults receiving CBRS.
  • Youth members will continue to have a 308-unit annual threshold before prior authorization is required.

To manage this change and minimize administrative burden, Magellan will begin entering authorizations in November 2025 for adult members currently receiving CBRS.

  • Authorization end dates will be randomly staggered over the first six months of 2026.
  • This approach ensures smoother renewals and avoids system bottlenecks.

New requests

  • Members newly requesting CBRS or members who were denied and have no active 2025 units must submit as new authorization requests.
  • Late notification penalties will be waived through Feb. 28, 2026, for these submissions.

Required documentation
CBRS authorization requests must include:

  • An updated comprehensive diagnostic assessment (CDA)
  • A current treatment plan
  • Progress toward goals, as applicable

Code summary
 

Questions?
If you have questions regarding the process to support members through this change or bill for dates of service on or after Jan. 1, 2026, please contact the Magellan provider network at IdahoProvider@MagellanHealth.com. 

Overview
Effective Jan. 1, 2026, Skills Training and Development (STAD) groups for adults will no longer be available through Magellan Healthcare, and the associated codes will no longer be billable for dates of service on or after January 1.

  • STAD: H2014
  • STAD: H2014 GT

Questions?
If you have questions regarding the process to support members through this change or bill for dates of service on or after Jan. 1, 2026, please contact the Magellan provider network at IdahoProvider@MagellanHealth.com. 

STAD will remain billable for members who are 17 years and younger, and for ages 18-21 through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit.  

Overview
Effective Dec. 1, 2025, the daily rate for Homes with Adult Residential Treatment (HART) will no longer be billable. All individual behavioral health HART Idaho Behavioral Health Plan services must be billed individually through Magellan Healthcare using the IBHP fee schedule. 

The following code will no longer be billable through Magellan for dates of service on or after Dec. 1, 2025. 

  • HART: H0046 HE
  • HART monitoring: H0046 HE U

HART services will follow IBHP individual service delivery requirements. 

Questions?
If you have questions regarding the process to support members through this change or bill for dates of service on or after Dec. 1, 2025, please contact the Magellan provider network team at IdahoProvider@MagellanHealth.com. 

Overview
Effective Dec. 1, 2025, the daily rate for Assertive Community Treatment (ACT) will no longer be billable. Individual behavioral health ACT services will be reimbursed based on Magellan Healthcare’s Idaho Behavioral Health Plan (IBHP) fee schedule.  

The following code will no longer be billable through Magellan for dates of service on or after Dec. 1, 2025. 

  • ACT: H0040 Q2 

With the transition of the Idaho Department of Health and Welfare’s Center of Excellence (CoE), providers delivering ACT services will follow IBHP individual service delivery requirements. For more information on continued CoE support, contact IDACTCoE@dhw.idaho.gov. Please also refer to the email notification from Monica Martin, Program Manager with the ACT CoE, from Oct. 28, 2025, which explains what support the ACT CoE is able to provide during their transition.

Questions?
If you have questions regarding the process to support members through this change or bill for dates of service on or after Dec. 1, 2025, please contact the Magellan provider network team at IdahoProvider@MagellanHealth.com. 

Overview
Effective Dec. 1, 2025, the daily rate for Early Serious Mental Illness (ESMI) will no longer be billable. Individual behavioral ESMI services will be reimbursed based on Magellan Healthcare’s Idaho Behavioral Health Plan (IBHP) fee schedule. 

The following codes will no longer be billable through Magellan for dates of service on or after Dec. 1, 2025.

  • ESMI: H0046 HI

For questions about training, support, and fidelity monitory, contact BHCoEESMI@dhw.Idaho.gov.

Questions?
If you have questions regarding the process to support members through this change or bill for dates of service on or after Dec. 1, 2025, please contact the Magellan provider network team at IdahoProvider@MagellanHealth.com. 

Overview
Effective Dec. 1, 2025, several services will no longer be available through Magellan Healthcare. These changes are being implemented network-wide and affect the services listed below.

  • Adult mental health peer support
    • Adult peer support: H0038 HB
    • Adult peer support, group: H0038 HB HQ
  • Mileage reimbursement
    • Transportation and mileage: T2002
    • Travel for professionals: S0215
  • Half-day partial hospitalization program (PHP) 
    • No new admissions on or after Dec. 1, 2025.
    • Members currently in half-day partial hospitalization program can continue receiving that level of care until it is no longer medically necessary.
    • ASAM 2.5 half day: H0035 HF
    • ASAM 2.5 half day: 0912 H0035 HF
    • All inclusive PHP half day: 0912 H0035
    • PHP eating disorder half day: H0035 U4
    • PHP eating disorder half day: 0912 H0035 U4

Magellan will work with impacted providers to assist with member transitions where necessary. 

Questions?
If you have questions regarding the process to support members through this change, please contact the Magellan provider network team at IdahoProvider@MagellanHealth.com. 

Overview
Effective Dec. 1, 2025, all Behavior Modification and Consultation (BMC) services will transition to Behavioral Intervention (BI). BMC services, which are currently authorized and reimbursed through Magellan Healthcare, must instead be billed to Idaho Medicaid’s Fee-for-Service (FFS) system managed by Gainwell Technologies (GWT). Behavioral Intervention is a covered service within Children's Habilitation Intervention Services (CHIS) and is reimbursed through Idaho Medicaid FFS, with prior authorization required through the Quality Improvement Organization, Telligen.

The following codes will no longer be billable through Magellan for dates of service on or after Dec. 1, 2025. 



Behavioral modification authorization requests will continue to be processed by Magellan through Nov. 30, 2025. Magellan is working with Idaho Medicaid to transfer all existing authorizations extending beyond Nov. 30, 2025, and new authorizations generated through Nov. 30, 2025, from Magellan to Idaho Medicaid’s Quality Improvement Organization (QIO) Telligen. Telligen will issue new prior authorizations. Claims for the new authorizations must be submitted to Idaho Medicaid’s Fee for Service (FFS) contractor Gainwell Technologies (GWT). 

Providers must be contracted with GWT in order to bill Idaho Medicaid directly for these services and must be registered with Telligen’s Provider Portal to obtain their authorization details. 

Magellan will work with impacted providers to assist with member transitions where necessary. Magellan members can also reach out to the Idaho Department of Health and Welfare, Medicaid Behavioral Health Integration Unit at MedicaidBHI@dhw.idaho.gov for assistance in finding a new provider.
 
Questions?
Please contact the Magellan provider network team at IdahoProvider@MagellanHealth.com.

If you have questions regarding the process to support members through this change or bill for dates of service on or after Dec. 1, 2025, please contact your provider relations specialist at GWT or you can contact GWT Provider Services at 1-866-686-4272. If you have questions about registering for Telligen’s provider portal, please contact Telligen at 1-866-538-9510 or IDMedicaidSupport@Telligen.com.