MedicaidPrior AuthHigh impact
Substance Use Disorder Intensive Outpatient Program - MEDICAID - OHIO (New)
Humana·OH · Psychiatry·Medicaid
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
Humana Healthy Horizons in Ohio establishes new prior authorization requirements and medical necessity criteria for Substance Use Disorder (SUD) Intensive Outpatient Program services (LOC 2) effective July 1, 2026. Billing teams must implement prior authorization workflows using ASAM criteria and ensure claims are submitted with required medical necessity documentation or face claim denials and financial penalties.
Action Required
By June 15, 2026: Billing team must establish prior authorization submission process for all SUD Intensive Outpatient Program (LOC 2) services under Humana Healthy Horizons Ohio Medicaid. (1) Obtain list of specific CPT and HCPCS codes requiring prior authorization from Ohio Medicaid Prior Authorization and Notification List linked in policy. (2) Configure billing software to flag these codes for prior auth requirement before claim submission. (3) Create authorization request submission protocol requiring providers to submit forms at least 2 days prior to service delivery for standard authorizations and 2+ days for expedited requests. (4) Ensure all SUD authorization requests include medical necessity documentation demonstrating ASAM Level of Care criteria compliance per Ohio Administrative Code Chapter 5160. (5) Train billing staff that failure to obtain prior authorization will result in claim denials, financial penalties to the practice, and reduced member benefits. (6) Update encounter forms and provider communication to require medical necessity justification at time of service request. Contact provider services at 877-856-5707 or OHMCDUM@humana.com to obtain specific code list and medical necessity criteria.