MedicaidPrior AuthHigh impact
Skin and Tissue Substitutes - MEDICAID - OHIO (Revised)
Humana·OH · Wound Care, Dermatology, General Surgery +3 more·Medicaid
Effective date
Jul 22, 2026
We identified it
Jul 23, 2026
Summary
Humana Healthy Horizons Ohio Medicaid establishes medical necessity criteria for coverage of skin and tissue substitutes (bioengineered cellular and acellular matrices) for treatment of diabetic foot ulcers and chronic venous leg ulcers lasting >4 weeks. The policy requires prior authorization and mandates comprehensive documentation including offloading, infection management, glycemic control, and wound care standards. Providers must submit authorization requests with medical necessity documentation before services are rendered to avoid claim denials and financial penalties.
Action Required
By July 22, 2026: Billing and clinical teams must implement the following: (1) Update prior authorization workflow in billing system to flag all skin and tissue substitute requests for mandatory pre-auth review before service delivery; (2) Providers must document ALL required criteria in medical record BEFORE submitting authorization: appropriate offloading, comprehensive wound assessment with ABI/perfusion testing, diabetes diagnosis confirmation, infection status/treatment plan, glycemic control measures, and moist wound dressing protocol; (3) Create authorization checklist and attach to encounter templates to ensure providers capture all mandatory elements; (4) Train front desk and billing staff to collect complete medical necessity documentation from providers before routing requests; (5) Submit authorization requests through provider portal with all supporting documentation attached; (6) Contact Humana provider services at 877-856-5707 or ODMCDUM@humana.com to request specific medical necessity criteria details; (7) Advise providers that services rendered without prior authorization will be subject to retrospective medical necessity review and potential claim denial. Failure to obtain authorization prior to service delivery may result in financial penalties to the practice and reduced member benefits.