Updates for Meridian Medicaid Plan, YouthCare, and Ambetter Health Behavioral Health Utilization Management
Date: 10/01/25
Effective January 1, 2026, the Illinois Health Care Protection Act establishes new requirements for utilization management and notification of behavioral health treatment for members of Merdian Medicaid Plan (Meridian), YouthCare HealthChoice Illinois (YouthCare), and Ambetter Health, our Health Insurance Marketplace product.
Please note the following new utilization management requirements
Guidelines for Meridian and YouthCare members with coverage for dates of service beginning January 1, 2026
- For inpatient behavioral health care, providers should notify Meridian or YouthCare within 48 hours of admission. If notification requirements are met, utilization review won’t be initiated for the first 72 hours of the admission.
- For substance use residential treatment, providers should notify us within 24 hours of initiation of services. Utilization review may begin after the 24-hour notification period.
- For outpatient behavioral health care, including partial hospitalization and intensive outpatient treatment, providers should notify us within 24 hours of initiation of services. Utilization review may begin after the 24-hour notification period.
HOW TO NOTIFY US: For all products, continue to submit notification of admission or initiation of treatment using your current method of seeking authorization.
Guidelines for Ambetter Health members with dates of service beginning January 1, 2026
There will be no review for behavioral health levels of care as follows:
- No review for the first 72 hours for inpatient mental health, inpatient detox, inpatient substance use or residential substance use.
- No review during the first 48 hours for partial hospitalization.
- No review during the first two business days for other outpatient behavioral health treatment—transcranial magnetic stimulation, electroconvulsive therapy, and psychological testing.
Preservice reviews may be required after the “no review” period.
If coverage is denied retrospectively, the participating provider shall not bill Meridian or YouthCare members and the insured shall not be liable for any treatment through the date the adverse determination is issued.
Ambetter members shall not be billed, and the insured shall not be liable for any treatment through the date the adverse determination is issued, other than any copayment, coinsurance, or deductible for which an Ambetter member may be responsible under the policy.
Always check member eligibility and benefits through Availity Essentials™, our secure provider portals, or your preferred vendor before rendering services to confirm prior authorization requirements and utilization management vendors, if applicable.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to Meridian and its family of plan. Meridian makes no endorsement, representation or warranties regarding any products or services regarding third party vendors and the products and services they offer.