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Prior authorization resources

Humana Healthy Horizons® in Ohio members may see any participating network provider, including specialists and inpatient hospitals. Humana Healthy Horizons in Ohio does not require referrals from primary care providers (PCPs) to see participating specialists; however, prior authorization must be obtained to see nonparticipating providers. Members may self-refer to any participating provider. PCPs do not need to arrange or approve these services for members, as long as applicable benefit limits have not been exhausted.

Medicaid provider signs a form

Services that require prior authorization

The Ohio Medicaid Prior Authorization List, PDF includes information about the services that require prior authorization.

Medicaid authorization process

Until the Ohio Department of Medicaid fully launches its Ohio Medicaid Enterprise System (OMES), providers who care for Medicaid recipients with coverage through Humana Healthy Horizons® in Ohio will submit prior authorizations via their secure Availity account.

After logging into your Availity account, please select the Humana OH Medicaid payer ID (61103) from the Payer dropdown before submitting an authorizations.

We will update you once ODM fully launches its OMES and providers must start submitting authorizations through the OMES front door via the ODM Provider Network Management (PNM) portal.

Community behavioral health authorization process

Please submit the Ohio Medicaid Community Behavioral Health Authorization Form to ask us to review your request for community behavioral health services. We will be unable to complete a medical necessity and level of care determination without receiving all required supporting documentation. Please complete and fax the form with all required documentation to 216-367-4077.

Community behavioral health authorization form, PDF

Please use the ODM 10276 “Substance Use Disorder Services Prior Authorization Request” form, PDF when submitting requests for Substance Use Disorder (SUD), Residential Treatment (H2034 and H2036), and Partial Hospitalization (H0015TG).

Please complete and fax the form with all required documentation to 216-623-2913.

Pharmacy authorization process

Ohio Medicaid managed care organizations use Gainwell Technologies as a single pharmacy benefit manager (SPBM). The SPBM utilizes a uniform Preferred Drug List (PDL) and utilization management policies developed by ODM. For more information, call Gainwell at 833-491-0344.

Learn more about prior authorization in the Humana Healthy Horizons in Ohio Provider Manual, PDF.

Nursing facility request process

Please submit the Ohio Medicaid Managed Care/MyCare Ohio Nursing facility request form to ask us to review your request for admission to a nursing facility. We will be unable to complete a medical necessity and level of care determination without receiving all required supporting documentation.

Nursing facility request form, PDF