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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.

Clinical coverage policies

Clinical coverage policies are resources for physicians and other Humana-contracted healthcare professionals providing care to our members enrolled in Humana Healthy Horizons in Ohio. Providers should review our clinical coverage policies, which we regularly review and update. Please note that these clinical coverage policies are subject to change.

Review our behavioral health clinical coverage policies

Review our pharmacy clinical coverage policies

Review our physical health clinical coverage policies

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.

We encourage all providers – participating and non-participating in the Humana Healthy Horizons in Ohio network – to create and utilize a secure Availity account.

Learn how to register for an Availity account and get additional information

After logging into your Availity account, please select “Humana” or “Humana Behavioral Health” from the Payer dropdown before submitting an authorization. This is different from Ohio Medicaid claims. For Ohio Medicaid claims, you must select “Humana Healthy Horizons (Ohio Medicaid) – Payer ID 61103” before submitting claims.

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.

Providers can request prior authorization to exceed coverage or benefit limits for members under the age of 21.

Community behavioral health authorization process

Please use 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 required documentation. Forms can be submitted via Availity Essentials (formerly Availity Portal).

Community behavioral health authorization form, PDF

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

ODM 10276 “Substance Use Disorder Services Prior Authorization Request” form, PDF

Please submit all forms for behavioral health services preauthorization requests through your secure Availity Essentials account.

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