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Professionally administered drugs prior authorization

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Prior authorization for professionally administered drugs 

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

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Oklahoma SoonerSelect: provider claims and payments

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Paper claims should be mailed to:
Humana Claims Office
P.O. Box 14359 Lexington
KY 40512-4359.

For electronic claims, sign in to your Availity Essentials account and select the Humana payer 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 of 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 electronic claims Humana Healthy Horizons issues payments within 30 days of receipt of a clean claim, and for all submitted paper claims, Humana Healthy Horizons issues payments within 45 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.

CGT-CMMI Model Participation

Oklahoma is participating in the CMS CGT-CMMI Model for Casgevy™ & Lyfgenia™. See below for supporting information for our billing providers:

Provider Billing Instructions:

Casgevy & Lyfgenia are on OHCA’s hospital carve out list. Both medications require prior authorization (PA) and are reviewed via medical benefit only. Criteria for both medications are found here.

If the prior authorization request is approved, and the member has been treated and discharged, the billing provider should:Submit the inpatient or outpatient hospital claim (based on place of service) which MUST NOT include the carve-out drug; and

Submit a separate claim on an outpatient hospital claim for the carve-out drug.Type of Bill to be used is 131;

Revenue Code 636 must be used;

Appropriate HCPCS code (or miscellaneous code if no specific code assigned) must be used;

NDC information must be billed on the HCPCS code line;

Purchase invoice showing the net cost for the drug therapy must be attached to the claim;

Claim will suspend for internal review and pricing.

These two claims are to be submitted at the same time. The claim for the carve-out drug will not be processed until both claims are received. 



Effective January 1, 2026, the Oklahoma Health Care Authority (OHCA) will no longer allow 340b providers to purchase the following therapies through the 340b program.Casgevy

Lyfgenia



A provider who submits a claim for administration of a State-Selected Model Drug must be a member of the CMS-designated patient registry for the Model and participate in a CMS-specified study. Participating Centers External Link



Primary and secondary point of contact for providers regarding single case agreements, PAs, and provider enrollment:TransplantContracting@humana.com

transplantleaders@humana.com



Working with Humana Healthy Horizons

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), Monday through Friday, 8 a.m. to 5 p.m., Central time.

Get paid faster

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

To access this tool:

Sign in to Availity Essentials (registration required).

From the Payer Spaces menu, select Humana.

From the Applications tab, select the ERA/EFT Enrollment app. (If you don’t see the app, contact the Availity Essentials administrator for your office 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.

How to submit a corrected claim in Availity Essentials

For Humana, only claims with a status of Finalized can be corrected. Adjusted Humana claims or Humana claims that were originally submitted as paper claims, encounters or delegated encounters cannot be corrected. To correct a claim, sign in to the Availity Essentials portal and select Claims & Encounters and then Claim Status to get started.   

Out-of-network claims

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 Medicaid fee schedule in Oklahoma. If the service is not available from an in-network provider and Humana Healthy Horizons makes 3 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.

Payment integrity and disputes

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 claim 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 Healthy Horizons’ 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 2 internal steps:

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 PPI audit or the termination of a provider agreement. Most issues are resolved at the reconsideration step.

Formal appeal: This is 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.

Claim overpayments

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.

Oklahoma Medicaid