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Provider Network Management and Single Pharmacy Benefit Manager

On October 1, 2022, Gainwell Technologies, the Single Pharmacy Benefit Manager (SPBM), began providing pharmacy services across all managed care plans and for all members.

The Ohio Department of Medicaid (ODM) will launch its Next Generation Medicaid program on Feb. 1, 2023. After, ODM will fully launch the full Ohio Medicaid Enterprise System (OMES) module to provide streamlined processes for claims, prior authorizations, and other administrative tasks for providers.

Providers should set up their OH|ID and associate their existing accounts. OH|ID is a secured web portal designed for Ohioans to access information and conduct business with a variety of state agencies, including Medicaid, in one place. The OH|ID is necessary for anyone that will access the OMES or SPBM modules.

Create and/or access your OH|ID account

ODM will send notices to providers about learning and training opportunities on various aspects of the Next Generation Program either via the mail and/or through announcements on the ODM website

Compliance training materials

The Centers for Medicare & Medicaid Services and state Medicaid contracts mandate that all Humana-contracted healthcare providers complete compliance trainings each year.

We recommend completing the trainings via your secure Availity account (registration required). After completing the trainings, you easily can submit an attestation of completion. The attestation is a requirement and lets us know that you completed the trainings.

We make the trainings available below as downloadable PDFs. You can review the below PDFs but must submit an attestation of completion through your Availity account.

How to complete your compliance training and attestation online (unless otherwise instructed):

Unless otherwise instructed:

  • Log into Availity.com
  • Select Payer Spaces – Humana
  • Select the ‘Resources’ tab
  • Select “Humana Compliance Events’
  • Select ‘I agree’ to the notice that pops up to indicate you are leaving Availity’s website.
  • If a security warning pops up indicating that you are navigating to https://sso2.archer.rsa.com, choose ‘Yes’ to proceed. You will be entering Humana’s secured compliance portal.
  • Follow the on-screen instructions to add, review and accept the compliance events.
  • Sign out in the upper right corner of the screen when all applicable events show ‘Complete.”

If you have questions, please call us at 877-856-5707 (TTY: 711), Monday – Friday, 7 a.m. – 8 p.m., Eastern time.

2023 Humana Healthy Horizons in Ohio Orientation and Training Module , PDF

This training includes information about Humana and Humana Healthy Horizons in Ohio, covered services, expanded services, contracting and credentialing, access-to-care requirements, preauthorization and notification, and other key topics we want our providers to have. We base these topics on our contract with the Ohio Department of Medicaid and on current Humana policies and procedures.

Learn more about the required Humana Healthy Horizons in Ohio Orientation and Training module and access other education resources, PDF

Cultural Competency Training , PDF

This training includes information about culture, cultural competence, clear communication, various subcultures and populations, strategies for working with seniors and people with disabilities, and additional information we want our providers to have.

Abuse, Neglect, and Exploitation (ANE) Training

The Humana Healthy Horizons Abuse, Neglect, and Exploitation Training includes information about risk factors, signs, scenarios, and resources, among other topics.

Watch a short Abuse, Neglect, and Exploitation (ANE) training video

00:00:00:10 - 00:00:27:25
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Welcome to the abuse, neglect and exploitation training. As you can imagine, abuse, neglect and exploitation is an extremely important topic for all of us working in Medicaid to be knowledgeable about. Within each of our roles, we should understand each a new term and understand the impact that abuse, neglect and exploitation can have on the vulnerable populations we serve and know what the signs and symptoms to look for.

00:00:28:21 - 00:00:54:00
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We will go through each of these in this training module as well as some scenarios for you to then test out your skills. Ending with additional resources. Abuse of a vulnerable population is a prevalent problem that often affects the victim as well as those around them. According to the National Council on Aging, up to 5 million older adults experienced some form of abuse, neglect or exploitation.

00:00:54:00 - 00:01:27:09
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In America every year. That abuse could occur in any location, including at home, at a facility or while out in the community. 60% of abusers are often family members. But what can we do? We can be knowledgeable about all the forms abuse can take, look out for signs of abuse and offer resources and help. Further statistics show that on average, one in ten individuals over the age of 60 have experienced a form of abuse and only a small percentage of which are then reported to the authorities.

00:01:28:09 - 00:02:00:27
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A vulnerable population includes those individuals that are in a racial or ethnic minority group children, elderly, socioeconomically disadvantaged, under-insured and uninsured, and those with certain medical conditions. This is not a comprehensive list, as there are many factors that contribute to an individual being in a vulnerable population or a vulnerable situation. We will review further in this training. Note that there are two factors that automatically place an individual in a vulnerable population, and those are social isolation and presence of dementia or Alzheimer's disease.

00:02:01:28 - 00:02:34:13
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Physical abuse can take on many forms. Physical abuse involves causing physical pain or injury to a vulnerable person by the use of physical force. Physical abuse can include, but is not limited to hitting, slapping, pushing, shaking, kicking, burning. Inappropriate use of drugs or physical restraints. Force feeding. Physical punishment. Homicide. Strangled. And suffocation. Confinement. Restraining or isolating a vulnerable person for any reason other than medical necessity.

00:02:35:10 - 00:03:02:00
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Deprivation and neglect have some common features, but are different. Let's explore them both. Deprivation is denying a vulnerable person medication, medical care, shelter, food needed medical equipment, slashed supplies, physical assistance, or exposing the person to physical, mental or emotional harm. Neglect is the failure to provide care or address the basic needs food, water, clothing and shelter of a vulnerable person.

00:03:02:25 - 00:03:36:01
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It can be intentional or unintentional and can also be self-inflicted. Self neglect is when a person fails to provide themselves with basic necessities and care, resulting in a risk to their health, safety or well-being. Emotional abuse is also varied in types, but often involves verbal assaults, threats of abuse, harassment, intimidation and or embarrassment. Financial abuse or exploitation is the misappropriation or misuse of a vulnerable persons money, property or resources.

00:03:36:22 - 00:04:02:21
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This is often conducted by a person who stands in a position of trust and confidence with the vulnerable person can involve the use of deception, intimidation or force. Sexual abuse is the touching, fondling, intercourse or any other sexual activity with a vulnerable person that is unable to understand or consent to such activity? Now that we have an understanding of the terms, let's get into what are some risk factors?

00:04:03:17 - 00:04:27:05
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Risk factors help us to understand and recognize situations in which abuse may be more likely to occur. Our risk factors are in two categories those that are unique to caregivers and then to members. Often, caregivers set out caring for their loved ones with the best of intentions. However, stress, combined with a multitude of other factors, can lead to abusive situations.

00:04:28:02 - 00:04:53:20
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Some of those factors include, but are not limited to alcohol and or substance abuse, mental illness, stress, lack of resources, education or support, physical limitations, health conditions, history of domestic violence or child abuse. Problems with housing, finances and or employment. Multiple demands from work dependance, family, etc.. As you can imagine, caring for another person takes time, attention and energy, which can be overwhelming and stressful.

00:04:54:15 - 00:05:21:06
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When you have a caregiver that is devoting their time and attention without support, this is a situation that could have a potential risk for abusive behavior. Earlier, we talked about two factors that increase a vulnerable person's risk for being abused. Those are social isolation and mental impairment, such as a diagnosis of dementia or Alzheimer's. Recent studies show that nearly half of those with dementia experienced abuse or neglect.

00:05:22:04 - 00:05:53:02
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Members that are isolated socially and members that have a mental impairment are unfortunately a target for abuse. Each of us can look out for these risk factors as well as members who are elderly or underage members. Members who do not understand or are not aware of their rights. Members who are depressed, have anxiety or other mental health issues, have limited mental capacity, are dependent on others financially or for care or help, have health conditions, have experienced the loss of a primary caregiver or a spouse and members with sensory impairments.

00:05:53:29 - 00:06:12:04
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Members may have a single or multiple risk factors that placed them at a higher risk for abuse, neglect or exploitation. Keep in mind that vulnerable adults who have experienced a form of abuse have a 300% higher risk for death than those who have not experienced abuse.

00:06:14:18 - 00:07:02:14
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Now that we understand the terms and the situations that lead to abuse, let's examine the specific warning signs that abuse is occurring. Some physical signs and symptoms that physical abuse can possibly be occurring are bruises, bleeding spots, burns marks, cuts, scrapes, broken bones, injuries, broken or missing sensory aids, torn clothing, dehydration or unusual weight loss, unsanitary or unsafe living conditions, poor hygiene, unattended medical needs, unintentional weight loss wearing clothing that are not appropriate for the weather or environment.

00:07:03:11 - 00:07:26:22
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Bedsores or pressure ulcers. Lack of funds for food, rent or mortgage bills or medications. Lack of utilities or utilities have been turned off. In other words, injuries or problems that are unexplained or do not coincide with the explanation given. This is not to say that any of these signs are definitive indications of abuse. They are warning signs of things.

00:07:26:22 - 00:07:59:29
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We need to pay attention to emotional signs that abuse is possibly occurring, appears fearful of caregiver, suddenly withdrawn or shy, avoiding answering questions, being overly complimentary of caregiver or suddenly criticizing caregiver stops, engaging in activities or socialization. Sudden onset of aggression, anger or agitation. Comments that caregiver is not listening. Treating member like a child. Critical harassing. Interrupting. Talking for a member.

00:07:59:29 - 00:08:35:29
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Demanding ignoring member stops. Talking when caregiver enters the room. Defers answering questions to caregiver who should report? State laws require certain people to report concerns of abuse, neglect and exploitation or other suspected acts of harm towards adults or children to appropriate authorities, agencies or other protective services. These requirements to report are often referred to as duties to report, and the individuals who are required to report are often referred to as mandated reporters.

00:08:36:26 - 00:09:05:23
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Some states require reporting by any person, but many states identify specific professionals as mandated reporters, which can include social workers, mental health professionals, medical professionals, or other individuals holding a professional license. If you have knowledge or information about our members during the course of your employment with Humana and you're uncertain whether you have a duty to report or a duty to warn or protect, you can promptly consult the appropriate governing body which regulates your profession.

00:09:06:20 - 00:09:33:24
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If you have suspicions of abuse, neglect or exploitation, notify the appropriate authorities, agencies and other protective services immediately. You are then required to immediately report internally by adhering to the following steps. One. Complete an occurrence report via the Humana Risk Management Occurrence Reporting System. If the situation involves a medicaid member, please select the critical incident Medicaid and LTC only occurrence type.

00:09:33:25 - 00:09:58:11
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When prompted to refer to the complete list of reportable occurrences for internal reporting by visiting the Risk Management SharePoint site, go slash rm3. Risk Management will notify the Privacy Office of any disclosures of HI upon submission of an incident report to the Risk Management Occurrence Reporting system. Be sure to include the following information in your report to risk Management.

00:09:59:07 - 00:10:25:15
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One Name of member two Name of organization contact where information was disclosed. Three Member ID. Four Date of Disclosure. Five Brief Description of Purpose and Content of Disclosure. Remember, in every interaction you have with a member to be aware of any signs for abuse, neglect and exploitation, you may be the only person in that member's life who is looking out for them.

00:10:26:11 - 00:10:36:04
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Our duty is to protect our members. For more information on any of the topics reviewed in this training, consult the following resources.

Health, Safety, and Welfare Education Training , PDF

This training includes information about abuse; neglect; exploitation; interventions; “handle with care” measures; reporting abuse, neglect, or exploitation; rights of mandated reporters; general reporting requirements; critical incidents; and information about Ohio agencies.

For more information about these required annual trainings and completing trainings via Availity:

Compliance Requirements for Healthcare Providers—Answers to Frequently Asked Questions , PDF

Completing training via Availity , PDF

Completing trainings manually , PDF

Additional resources

Relias

Humana Healthy Horizons in Ohio providers have access to Relias—a web-based library available through your secure Availity account.

Through Relias, you can explore topics like:

  • Addiction
  • Behavioral health
  • Integrated care
  • Mental health

Access the Relias library

These behavioral health-focused training modules provide integrated information to support comprehensive care and address unique member needs. The extensive Relias library is comprised of courses designed to improve the likelihood of success in the emerging value-based healthcare delivery system. You also can earn continuing education credits by completing these courses.

For more information, please call Provider Services at 877-856-5707, Monday – Friday, 8 a.m. – 6 p.m., Eastern time.

Altruista (population health module)

Altruista is our population health module. This module helps physicians monitor clinical measures identified and executed for members assigned to their panel. Access this module by:

  • Signing in to Availity
  • Navigating to the Humana Payer Spaces section
  • Selecting Resources

The Ohio Medicaid Care Management link will direct providers to the population health dashboard. This allows providers to view member assessments, care plans, authorizations, assigned care management programs, and contact information for the member’s care manager.