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