Oklahoma SoonerSelect: provider claims and payments

Paper claims should be mailed to Humana Claims, P.O. Box 14601, Lexington, KY 40512-4601.

For electronic claims, sign in to your Availity Essentials account and select the Humana Medicaid payer ID (61101 for fee-for-service claims) from the Payer drop-down menu before submitting.

Humana Healthy Horizons ensures their compliance target and turnaround times for electronic claims to be paid/denied comply within the following time frames:

• Humana pays 90% of all clean claims submitted from providers within 14 calendar days from the date of receipt.
• Humana pays 99% of all clean claims from providers within 90 calendar days of the date of receipt.

For all submitted claims, both paper and electronic, Humana Healthy Horizons issues payment within 45 calendar days of receipt of a clean claim, in which all requested documentation is provided, in the proper format, and does not contain any material defect, error or impropriety.

Below we include information about electronic fund transfers, out-of-network claims, payment integrity, overpayments and disputes.

If you have any questions at all, or need other information, contact Provider Services at 855-223-9868 (TTY:771).

Get paid faster and reduce administrative paperwork electronic funds transfer (EFT) and electronic remittance advice (ERA). Healthcare providers can use Humana Healthy Horizons’ ERA/EFT enrollment tool on Availity Essentials to enroll.

To access this tool:

1. Sign in to Availity Essentials (registration required).
2. From the Payer Spaces menu, select Humana.
3. From the Applications tab, select the ERA/EFT Enrollment app. (If you don’t see the app, contact an Availity administrator to discuss your need for this tool.)

When you enroll in EFT, Humana Healthy Horizons claim payments are deposited directly in the bank account(s) of your choice.

Humana Healthy Horizons established guidelines for payments to out-of-network providers for preauthorized medically necessary services. Except as otherwise precluded by law and/or specified for Indian Health Care Providers, Federally Qualified Health Centers, Rural Health Clinics and certified community behavioral health clinics, services are reimbursed at 90% of the Oklahoma Medicaid fee schedule. If the service is not available from an in-network provider and Humana Healthy Horizons makes three documented attempts to contract with an out-of-network provider, Humana Healthy Horizons may reimburse that provider less than the Medicaid fee-for-service rate.

At Humana, we strive to offer our members high-quality healthcare at affordable rates. To achieve this goal, the Humana Provider Payment Integrity (PPI) department reviews claims payments for accuracy and requests refunds if claims are overpaid or paid in error.

Common reasons for overpayment include:

• An issue regarding the coordination of member benefits
• Duplicate payments
• Fraud, waste and abuse detection
• Incorrect provider reimbursement
• Medical coding reviews
• Medical record reviews
• Member plan termination
• Subrogation

If you are not satisfied with Humana’s policies and procedures or a decision made by Humana Healthy Horizons that does not impact the provision of services to members, you may file a provider complaint. The provider complaint system consists of two internal steps:

1. Reconsideration: The first step in the provider complaint system, a reconsideration represents your initial request for an investigation into a denied claim, Humana Healthy Horizons’ policies and procedures, findings of a provider payment integrity (PPI) audit, or the termination of a provider agreement. Most issues are resolved at the reconsideration step.
2. Formal appeal: The second step in the process; if a provider disagrees with the outcome of the reconsideration, an additional review known as a formal appeal can be made.

Providers must report to Humana Healthy Horizons all service claim overpayments for medical services rendered to SoonerSelect managed care plan members, in accordance with Humana Healthy Horizons’ contract with the Oklahoma Health Care Authority (OHCA), within 60 days of identification of the overpayment. Regardless of agreement specifics, the provider or subcontractor must submit such claims after the date on which the overpayment was identified and notify Humana Healthy Horizons in writing of the reason for the overpayment as required by 42 CFR 438.608.

Refund checks for overpayments can be mailed to:
Humana Healthcare Plans
P.O. Box 931655
Atlanta, GA 31193-1655

Humana Healthy Horizons reports all overpayments to OHCA Program Integrity. These reports include all unsolicited provider refunds.