Skip to main content

Claims and payments

Below, we include information about—and links to additional information about—authorizations and referrals, electronic claims submissions, claims edits, educational presentations, and more. You can find additional information in the Humana Healthy Horizons in Ohio Provider Manual, PDF.

Medicaid provider works online

Get paid faster

Have your Humana claims payments deposited automatically with electronic funds transfer (EFT) and electronic remittance advice (ERA). Visit Humana.com/EpaymentInfo for more information on EFT and ERA.

Single pharmacy benefit manager

The single pharmacy benefit manager (SPBM) is a specialized managed care program operating as a prepaid ambulatory health plan (PAHP) that will provide pharmacy benefits for the entire Medicaid Managed Care population (excluding MyCare members) in Ohio. Gainwell Technologies serves as the SPBM in Ohio.

Access the Ohio Medicaid Pharmacy Services Web Portal

An additional integral component to the new pharmacy model is the Pharmacy Pricing and Audit Consultant (PPAC), which will conduct actual acquisition cost surveys, including the cost of dispensing surveys, and perform oversight and auditing of the SPBM. ODM has selected Myers and Stauffer, LLC, as the PPAC vendor.

The SPBM will consolidate the processing of retail pharmacy benefits and maintain a pharmacy claims system that will integrate with the Ohio Medicaid Enterprise System (OMES), new managed care organizations, pharmacies, and prescribers. The SPBM also will work with pharmacies to ensure member access to medications, supporting ODM’s goals of providing more pharmacy choices, fewer out-of-network restrictions, and consistent pharmacy benefits for all managed care members. The SPBM also will reduce provider and prescriber administrative burden by utilizing a single set of clinical policies and prior authorization procedures, as well as a single pharmacy program point of contact for all members.

All Medicaid managed care members will be automatically enrolled with the SPBM under a 1915(b) waiver. Additionally, Gainwell Technologies will be required to contract with all enrolled pharmacy providers that are willing to accept the SPBM contract terms, resulting in a broad pharmacy network that will ensure access for all members statewide.

For more information about the SPBM or PPAC initiatives, please email MedicaidSPBM@medicaid.ohio.gov.

Out-of-network claims

Humana Healthy Horizons in Ohio established guidelines for payments to out-of-network providers for preauthorized medically necessary services. These services will be reimbursed at no less than 100% of the Ohio Medicaid fee schedule. If the service is not available from an in-network provider, Humana Healthy Horizons in Ohio may reimburse that provider less than the Medicaid Fee for Service rate.

Emergency and post-stabilization care services

We cover and pay for emergency and post-stabilization care services. This includes ensuring the determination of the attending emergency physician, or the provider actually treating the member, of when the member is sufficiently stabilized for transfer or discharge.

The Humana Healthy Horizons in Ohio Provider Manual, PDF includes additional information about emergency and post-stabilization care services.

Claims payment inquiries

Learn about our claims payment processes and get answers to frequently asked questions about getting your claims paid.

Claims payment inquiries

Payment integrity and disputes

View our policies and procedures for ensuring claims accuracy and handling payment discrepancies.

Payment integrity and disputes

Reconsiderations and appeals

Get information about medical claim payment reconsiderations and member appeals for Humana participating and nonparticipating physicians, hospitals, and other healthcare providers.

Reconsiderations and appeals

Claims Payment Systemic Error Report

The Claims Payment Systemic Error (CPSE) report includes information about claims adjudication that is incorrectly paying, denying, or suspending and is affecting or potentially may affect five or more billing providers.

Access the CPSE report, PDF