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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

Providers should review the Ohio Medicaid Prior Authorization List online at Humana.com/PAL.

Prior Authorization submission—process and format

Prior authorization requests must be submitted to Gainwell Technologies via the Ohio Department of Medicaid’s (ODM’s) Provider Network Management (PNM) portal. Gainwell will serve as the single, centralized location for provider submissions of prior authorization requests for all medical (nonpharmacy) services.

Prior authorization forms are available via the Gainwell Technologies website.

Pursuant to Ohio Revised Code 5160.34, ODM has consolidated links to Medicaid prior authorization requirements.

Access information about and updates to prior authorization requirements for ODM-administered services and managed care organization-administered services

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.