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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 on appeal to deny, limit, reduce, suspend, or terminate a covered service for lack of medical necessity. Services denied, limited, reduced, suspended, or terminated for reasons other than lack of medical necessity, and for which we did not complete a medical review, 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

To request external medical review after our decision, on appeal, to deny, reduce, suspend, or terminate a covered service for lack of medical necessity, providers must submit a written request to Permedion within 30 calendar days of receiving written notification that they have exhausted the internal appeals process.

Providers must complete the Ohio Medicaid MCE External Review Request form, available on the Permedion website. Once there, select “Contract Information” and “Ohio Medicaid” to download a PDF of the form.

After completing the form, gather all required documentation, which can include:

  • Copies of all adverse decision letters (initial and appeal) you received from us
  • All medical records, statements (or letters) from treating healthcare providers
  • Other information you want considered when reviewing your EMR request

Finally, securely submit the form and supporting documentation to Permedion.

The first time you have an EMR request to submit to Permedion, email to establish access to the submission portal.

For information about the EMR process, call Permedion at 800-473-0802, Option 2.

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

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.