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External medical review

Humana Healthy Horizons® in Ohio offers an external medical review to a provider who is unsatisfied with the Humana Healthy Horizons in Ohio decision to deny, limit, reduce, suspend, or terminate a covered service for lack of medical necessity. Services that are denied for reasons other than lack of medical necessity are not subject to external medical review.

Medicaid provider works on the computer

Medical necessity criteria

Humana Healthy Horizons in Ohio uses the following criteria to determine medical necessity:

  • Ohio state regulations
  • Milliman Care Guidelines (MCG)
  • American Society of Addiction Medicine (ASAM) criteria, which are nationally recognized, evidence-based clinical utilization management (UM) guidelines
  • Humana coverage policies

These guidelines are intended to allow Humana Healthy Horizons in Ohio to provide all members with care that is consistent with national quality standards and evidence-based guidelines. These guidelines are not intended as a replacement for a physician’s medical expertise; they are to provide guidance to our physician providers related to medically appropriate care and treatment.

External medical review process

The external medical review process:

  • Is available at no cost to the provider
  • Does not interfere with the provider’s right to request a peer to peer review
  • Does not interfere with a member’s right to request an appeal or state hearing

A provider must submit a request for an external medical review within 30 calendar days of receiving the Humana Healthy Horizons in Ohio decision.

You can file an external medical review verbally or in writing. To file an external medical review:

  • Call 877-856-5707 (TTY: 711)
  • Send an external medical review request to us with the following information:
    • Member name
    • Member identification number from the front of the member’s Humana Healthy Horizons in Ohio member ID card
    • Member address and phone number
    • Explanation of issue

Send this written information to:
Humana Healthy Horizons in Ohio
Grievance and Appeal Department
P.O. Box 14546
Lexington, KY 40512-4546

Or fax this written information to 800-949-2961

Following the external medical review, a letter is sent within:

  • 24 hours for requests associated with expedited service authorization decisions
  • 30 days for requests associated with standard service authorization decisions
  • 60 days for requests associated solely with provider payment(s)

The external medical review decision is final and binding. If the external medical review determination is reversed, Humana Healthy Horizons in Ohio will authorize the services within 72 hours or pay for the disputed service within the time frames established for claims payment.

See the Humana Healthy Horizons in Ohio Provider Manual, PDF for other information about the grievances and appeals process.