We are proud to partner with the Ohio Department of Medicaid (ODM) through its Next Generation Medicaid program to help improve wellness and health outcomes for Medicaid recipients in Ohio. We include below important information for all Ohio Medicaid healthcare providers.
Important: ODM will not yet deny claim denials associated with data integration to ensure readiness
Continue to make your Provider Network Management updates. ODM met with key stakeholders regarding ODM’s direction to deny claims due to data misalignment between the managed care entities’ (MCE) systems and Ohio Medicaid’s Provider Network Management (PNM) system-generated Provider Master File beginning Oct. 20, 2023. Based on the feedback and discussion, ODM determined MCEs will not be denying claims for PNM system data misalignment at this time. ODM will continue to work with the MCEs to determine a date in the future to initiate this process.
Ongoing action required: Providers or trading partners.
Providers should continue to update their data in the
Join our Humana Healthy Horizons in Ohio Provider Advisory Council
Through the Provider Advisory Council (PAC), Humana Healthy Horizons® in Ohio aims to gather input and to discuss and learn about issues affecting providers. It also serves as a forum to identify challenges, solve problems, share information and collectively find ways to strengthen the healthcare service delivery system. The PAC is one of many ways Humana Healthy Horizons plans to present new information and receive direct feedback from the provider network.
If you would like to join our PAC, email
Upcoming council meeting
Thursday, Dec. 19, 2024, 3 p.m. – 5 p.m.
Exciting changes to Ohio’s Medicaid program as of Feb. 1, 2023
The Next Generation managed care plans, new Electronic Data Interchange (EDI) module and Fiscal Intermediary (FI) have been implemented. With the launch of the new EDI and FI, there are some changes for providers.
Claims and prior authorization (PA) requests submitted through a trading partner
Key changes effective Feb. 1
- ODM’s new EDI begins accepting trading partner fee‐for‐service (FFS) and managed care claims.
- Provider claims submitted to trading partners must include the Medicaid member ID (MMIS).
- The member’s Medicaid ID should be obtained with each encounter.
- Member eligibility can be verified using the ID through the PNM module, which redirects to the Medicaid Information Technology System (MITS).
- For professional claims, only one rendering provider is allowed per claim. Individual claims must be submitted for services rendered by different providers. (See exceptions for Federally Qualified Health Centers and Rural Health Clinics in “Rendering Provider on Claims Submissions.”)
What did not change on Feb. 1
- FFS prior authorization requests continue to be submitted through the PNM module link to MITS.
- Managed care prior authorization requests continue to be submitted to each plan using their existing processes.
- The new EDI will not accept prior authorization requests of any kind.
Portal submitted claims and all prior authorization requests
Key changes effective Feb. 1
- All Next Generation plans will have portals for direct data entry. Providers should consult their
provider handbook for instructions on how to bill using the portal. - FFS claims will continue to be submitted through the PNM module link to MITS.
- The Medicaid Management Information System (MMIS) ID will be the identifying number used for FFS claims processing.
What did not change on Feb. 1
- Continue using managed care plan portals to direct data enter claims and prior authorization requests.
- Plan eligibility continues to be accessed through managed care organization (MCO) portals.
- Continue using the PNM module, which redirects to MITS, to submit, adjust, and search FFS claim and prior authorization information.
The Next Generation managed care plans changes do not apply to MyCare Ohio plans, which will continue to provide benefits to Ohioans who receive Medicaid and Medicare benefits, with enhanced coordination of medical, behavioral, and long-term care services.
For additional information and resources about the Feb. 1 changes, visit the
Help desks are available to assist providers.
- If you have questions about streamlined claims, prior authorization requests, administrative processes, the PNM module, OH|ID or portal password support, call the ODM Integrated Help Desk at
800-868-1516 or emailIHD@medicaid.ohio.gov . - For billing and prior authorization guidance, call Humana Healthy Horizons at 877-856-5707, Monday – Friday, 7 a.m. – 8 p.m., Eastern time.
Need help?
Introducing Humana Healthy Horizons in Ohio
Humana Healthy Horizons has served Medicaid populations continuously for more than 2 decades and currently manages Medicaid benefits for nearly 800,000 members nationally. We developed expertise providing care management, care planning, and specialized clinical management for the complex needs of members within a social supports‐based framework.
We also developed significant expertise in integrating physical health, behavioral health, pharmacy and social services and supports for a whole-person centered approach to improving the health and well‐being of our members and the communities we serve.
In Ohio, Humana already serves 568,000 residents through Medicare Advantage, Medicare prescription drug plans, commercial employer-sponsored plans, commercial dental and vision coverage, and TRICARE.
For more than two decades, Humana has served Medicaid populations and currently manages Medicaid benefits for nearly 800,000 enrollees nationwide. Humana Healthy Horizons is committed to continue demonstrating our ability to manage complex populations and create solutions that lead to a better quality of life for our members.
We are pleased to announce that Humana Healthy Horizons in Ohio is launching in early 2022. In partnership with the Ohio Department of Medicaid, we will work with our provider network to serve our members in Ohio, and help them reach their health goals and get the right care in the right place at the right time.
Helping keep our members in their best health is what human care is all about.
Humana Healthy Horizons in Ohio Provider Orientation and Training
All contracted providers are required to complete orientation and training. This training includes information about Humana and Humana Healthy Horizons in Ohio, covered services, expanded services, contracting and credentialing, access-to-care requirements, preauthorization and notification, and other key topics. We base these topics on our contract with ODM and on current Humana policies and procedures.
We hold virtual training sessions on the second Thursday of each month at 2 p.m., Eastern time, and on the fourth Tuesday of each month at 11:30 a.m., Eastern time.
Join our network
By working closely with our providers, we can help our members in Ohio:
- Develop strong relationships with their primary care provider
- Get the right care in the right place at the right time
- Set and reach health goals
Once ODM completes implementation of its Next Generation Medicaid program, Humana Healthy Horizons in Ohio will administer care focused on Temporary Assistance for Needy Families, Expansion, and Assisted, Blind, and Disabled populations in the west, northeast, and central/southeast regions.
Submit your application and documentation
You can submit your enrollment application and supporting forms and documents Through Availity Essentials®
- Sign in to
Availity Essentials (Register for an account if you don’t yet have one.) - Select “Payer Spaces” then “Humana” in the top header
- Select the Applications tab in the middle of the page
- Scroll down to select “Join our Network”, then follow the prompts to complete the form and submit your application.
For additional information about joining our network:
Email:
Call: 877-856-5707, Monday – Friday, 7 a.m. – 8 p.m., Eastern time
Join our dental network
DentaQuest administers the Humana Healthy Horizons in Ohio dental plan. To join our dental network:
-
Create an account in the Ohio Medicaid credentialing PNM module , and then - Register with DentaQuest for Humana Healthy Horizons:
- By using the
DentaQuest online provider portal , or - By calling the Humana DentaQuest provider phone line at 833-615-0432, Monday – Friday, 7 a.m. – 8 p.m., Eastern time
- By using the
Existing DentaQuest providers who want to join the Humana Healthy Horizons in Ohio dental network can contact their DentaQuest representative for more information.
About Humana Healthy Horizons in Ohio
Nationally, we serve Medicaid members through:
- Medicaid Managed Care (MMC)
- Managed Long-term Services and Supports (MLTSS) programs
- Centers for Medicare & Medicaid Services (CMS) Financial Alignment Initiative Dual Demonstrations
- Medicare Advantage (MA)
- Dual Special Needs Plans (D-SNPs)
- Prescription drug plans (PDPs)
Humana Healthy Horizons in Ohio is a Medicaid Product of Humana Health Plan of Ohio, Inc.
Provider resources
We want to make working with us as easy as possible. Access key
Ohio Medicaid
- Humana Healthy Horizons in Ohio
Answers to FAQs Availity Behavioral and physical health clinical coverage policies Behavioral Health Tool Kit Claims and payments Clinical practice guidelines Communications and network notices Documents and resources External medical review Join our network Optimization of pregnancy outcomes Pharmacy Pharmacy clinical coverage policies Prior authorization Provider network management Services for children Telehealth services Training materials