Humana Healthy Horizons in Ohio

February 2023 update: Please be aware that some Humana Healthy Horizons^® in Ohio Medicaid member ID cards were sent out with values mismatched under Member ID Number and Plan ID Number fields. Learn what this means for you and what we’re doing for our affected members, PDF.

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 activities for providers that have stayed the same and some that have changed.

Claims and prior authorization (PA) 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).
  • Medicaid ID should be obtained with each encounter.
  • Member eligibility can be verified using the ID through the Provider Network Management (PNM) module, which redirects to 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 authorizations will continue to be submitted through the PNM module link to MITS.
• Managed care prior authorizations will continue to be submitted to each plan using their existing processes.
• The new EDI will not accept prior authorizations of any kind.

Portal submitted claims and all prior authorizations

Key changes effective Feb. 1

• All Next Generation plans will have portals for direct data entry and 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.
  • 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 authorizations.
• Plan eligibility will continue to be accessed through MCO portals.
• Continue using the PNM module, which redirects to MITS, as you do today 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 launch, 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 authorizations, administrative processes, the PNM module, OH|ID, or portal password support, contact the ODM Integrated Help Desk (IHD) at 800-868-1516 or IHD@medicaid.ohio.gov.
• For billing and prior authorization guidance, call us at 877-856-5707, Monday – Friday, from 7 a.m. – 8 p.m., Eastern time.

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

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 improve 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.

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.

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:

• First, create an account in the Ohio Medicaid credentialing Provider Network Management module, and then
• Register with DentaQuest for Humana:
  • 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. We make available the key documents and forms you need to work with us and get paid. Check out the Humana Healthy Horizons in Ohio Provider Manual, PDF, learn about our claims process, get answers to frequently asked questions, and more.

See a sample network provider contract by provider type, PDF