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  Resources for Providers webpage of the Next Generation website

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 email  IHD@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.

Get information about who to contact depending on the help you need

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.

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.

Register for a Thursday training session .

Register for a Tuesday training session .

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^®

1. Sign in to Availity Essentials (Register for an account if you don’t yet have one.)
2. Select “Payer Spaces” then “Humana” in the top header
3. Select the Applications tab in the middle of the page
4. 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: OhioNetworkSpecialist@humana.com

Call: 877-856-5707, Monday – Friday, 7 a.m. – 8 p.m., Eastern time

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

Existing DentaQuest providers who want to join the Humana Healthy Horizons in Ohio dental network can contact their DentaQuest representative for more information.

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.

We want to make working with us as easy as possible. Access key documents and forms for fast and efficient compensation. Access the Humana Healthy Horizons in Ohio Provider Manual , learn about our claims process , get answers to frequently asked questions , and more.

See a sample network provider contract by provider type