stethoscope

Join our network and find credentialing information.

Log in to Availity Essentials™ to access patient benefits, claims information and more.

Find tools and materials to support doing business with us.

Learn more about research and trends that impact your practice.

Find self-service info and phone numbers and update your provider data.

Review prior authorization lists for services, medications and submission guidance.

Prior authorization submission information

Professionally administered drugs prior authorization

Find appeals guidelines and payment policy information.

Learn how to submit claims and find coding guidance.

Find policies for procedures, devices and medications.

Review guidelines and health programs to support your patients and practice.

Find dental benefits, tools and resources.

Prior authorization for professionally administered drugs 

Locate state-specific resources for Humana Healthy Horizons® (Medicaid).

compass

Shop plans, learn about Medicare and explore member resources.

Search for in-network medical, vision, dental and pharmacy providers.

External medical review

A female healthcare professional looking closely at information on a computer

Humana Healthy Horizons in Ohio uses the following criteria to determine medical necessity:

Ohio state regulations

Milliman Care Guidelines (MCG)

American Society of Addiction Medicine (ASAM) criteria, which are nationally recognized, evidence-based clinical utilization management (UM) guidelines

Humana coverage policies

These guidelines are intended to allow Humana Healthy Horizons in Ohio to provide all members with care that is consistent with national quality standards and evidence-based guidelines. These guidelines are not intended as a replacement for a physician’s medical expertise; they are to provide guidance to our physician providers related to medically appropriate care and treatment.

External medical review process

To request external medical review after our decision, on appeal, to deny, reduce, suspend, or terminate a covered service for lack of medical necessity, providers must submit a written request to Permedion within 30 calendar days of receiving written notification that they have exhausted the internal appeals process.

Providers must complete the Ohio Medicaid MCE External Review Request form, available on the Permedion website. Once there, select “Contract Information” and “Ohio Medicaid” to download a PDF of the form.

After completing the form, gather all required documentation, which can include:

Copies of all adverse decision letters (initial and appeal) you received from us

All medical records, statements (or letters) from treating healthcare providers

Other information you want considered when reviewing your EMR request

Finally, securely submit the form and supporting documentation to Permedion.

The first time you have an EMR request to submit to Permedion, email IMR@gainwelltechnologies.com to establish access to the submission portal.

For information about the EMR process, call Permedion at 800-473-0802, Option 2.

The external medical review process:

Is available at no cost to the provider

Does not interfere with the provider’s right to request a peer to peer review

Does not interfere with a member’s right to request an appeal or state hearing

Following the external medical review, a letter is sent within:

24 hours for requests associated with expedited service authorization decisions

30 days for requests associated with standard service authorization decisions

60 days for requests associated solely with provider payment(s)

The external medical review decision is final and binding. If the external medical review determination is reversed, Humana Healthy Horizons in Ohio will authorize the services within 72 hours or pay for the disputed service within the time frames established for claims payment.

See the Humana Healthy Horizons in Ohio Provider Manual for other information about the grievances and appeals process.

Medical necessity criteria

Ohio Medicaid