---
title: Humana Healthy Horizons in Ohio ABA coverage (Next Gen MCO).
url: "https://carelu.com/payers/humana-healthy-horizons-ohio"
markdown_url: "https://carelu.com/payers/humana-healthy-horizons-ohio.md"
state: OH (Ohio)
payer: Humana Healthy Horizons in Ohio
kind: Medicaid managed care plan (MCO)
parent_program: Ohio Medicaid
description: "How Humana Healthy Horizons administers Ohio Medicaid ABA — prior authorization on every ABA code per its PA list, in-house behavioral UM, Availity submission, and the retrospective-review penalty for skipping PA."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Humana Healthy Horizons in Ohio ABA coverage (Next Gen MCO).

_Payer Guide · Humana Healthy Horizons (OH) · Last updated September 2026 · 2 primary sources_

> Cleanest all-codes PA statement in Ohio; state-policy criteria plus Availity logistics.

Humana Healthy Horizons in Ohio administers ABA on the state clinical framework with the cleanest all-codes PA statement of the seven plans: its prior-authorization list (effective January 2026) names every ABA code — 97151 through 97158, 0362T, and 0373T — with no assessment exemption. There's no distinct Humana clinical policy layered on top; what the plan adds is in-house behavioral UM, Availity logistics, and a sharp consequence for skipping the process.

This plan administers the **Ohio Medicaid** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Ohio Medicaid guide](https://carelu.com/payers/ohio-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — the PA list covers every ABA code (97151–97158, 0362T, 0373T), assessments included [1]
- **Prior auth for treatment**: Required — same list; unauthorized services face retrospective review and financial penalties [1]

## At a glance

- **Plan type:** Ohio Next Generation MCO
- **Clinical rules:** State OAC 5160-34 framework — no distinct plan ABA policy
- **Prior auth:** Every ABA code on the PA list (eff. 1/1/2026), assessments included
- **Skip-PA consequence:** Retrospective medical-necessity review + financial penalties
- **Submission:** Availity Essentials; provider line (877) 856-5707
- **UM:** In-house Humana behavioral health

## How Humana runs ABA authorization

The PA and notification list is unambiguous: "Applied behavioral analysis (ABA) therapy" covers 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, and 0373T — so unlike Buckeye (or the DMAS-style structures elsewhere), the assessment itself needs authorization before the first appointment, and intake should sequence accordingly. Services rendered without PA are subject to retrospective medical-necessity review and financial penalties, which converts a skipped authorization into a revenue write-off risk. Submissions run through Availity Essentials (registration at 800-AVAILITY), with the Ohio provider line at (877) 856-5707. Clinical criteria follow the state framework — DSM-5-TR diagnosis, 6-month reviews — and the OhioRISE rule holds: ABA bills to Humana, never to OhioRISE. [1]

## Intake gates

The questions that decide whether a family can start with Humana Healthy Horizons in Ohio, and what they have to bring.

- **Who may diagnose**: Follows the Ohio Medicaid framework: the ASD diagnosis comes from a documented comprehensive diagnostic evaluation by a licensed physician, psychologist, or other clinician qualified to diagnose autism, demonstrating DSM-5-TR criteria. [2][1]
- **Referral required?**: No referral or service order requirement is published, and Humana layers no distinct ABA clinical policy on the state framework. What it does publish is the cleanest all-codes prior-authorization statement in Ohio: the PA and notification list effective January 1, 2026 puts "Applied behavioral analysis (ABA) therapy" against 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T and 0373T, with no assessment exemption — so the assessment itself needs authorization before the first appointment. Services rendered without PA are subject to retrospective medical-necessity review and financial penalties. Submissions run through Availity Essentials; the Ohio provider line is (877) 856-5707. [2][1][1]
- **Prior-auth decision time**: Humana’s 2026 Ohio manual still prints the older standard clock: notice “no later than 10 calendar days following receipt of the request for service.” Expedited and urgent behavioral health decisions come “no later than 48 hours after receipt,” and concurrent decisions within three calendar days. OAC 5160-26-03.1 has required 7 calendar days for standard decisions since 1/1/2026, so 7 days is the binding outer limit. No ABA reauthorization lead time is published. Ohio’s MCO rule sets the clock. For a standard request the MCO “must provide notice to the provider and member as expeditiously as the member’s health condition requires but no later than seven calendar days following receipt of the request for service,” extendable by up to fourteen calendar days (an MCO-requested extension needs ODM’s prior approval). An expedited decision is due “no later than forty-eight hours after receipt of the request for service” (OAC 5160-26-03.1, effective 1/1/2026). The 48 hours is stricter than the federal 72-hour managed-care cap. [3][4]
- **Other insurance (who pays first)**: Humana’s Ohio manual: “Humana Healthy Horizons in Ohio collects COB information for our members … Medicaid programs are the payer of last resort.” A COB claim needs the primary carrier’s remittance or payment information. When Humana is secondary, it recommends submitting “within 180 days from the other insurance payment date.” Its timely-filing limit is “at least 90 days from the date of the remittance advice” of the other payer. If a claim is denied for missing COB information, send the primary remittance within the rest of the initial timely-filing period. The manual does not say whether Humana’s authorization is still needed when a commercial plan pays first. Ohio’s MCO rule: “The MCE is the payer of last resort when a member has third party resources available.” Providers must “take reasonable measures to obtain all third party payments and file claims with all TPPs prior to billing the MCE.” That means a remittance from the other payer showing a valid non-payment reason (service not covered, applied to the deductible or copay, benefit maximum reached), a partial payment with its remittance, or no response within ninety days of submitting to the other payer. The MCO pays at most its allowed amount minus the other payments, and must allow at least ninety days from the other payer’s remittance to file. Exception: “The MCE, except SPBM, pays first for preventive pediatric services before seeking reimbursement from any liable third party.” Children in the custody of a county children’s services agency are exempt from TPL cooperation (OAC 5160-26-09.1). [4][5]
  - Ask the plan: Humana Healthy Horizons in Ohio Provider Services: whether a Humana ABA authorization is required when a commercial plan pays first.
- **Telehealth** _(ask the plan)_: No plan-specific ABA telehealth rule found; ODM’s Telehealth Services guidance for managed care entities and the Telehealth Billing Guidelines set the underlying rules. [2][1]
  - Ask the plan: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.

## Delivery and billing rules

Coverage decides whether Humana Healthy Horizons in Ohio pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Bill as provider**: Follows the Ohio Medicaid framework: independent practitioners are Certified Ohio Behavior Analysts (ORC Chapter 4783) or BACB BCBAs and BCBA-Ds enrolled with ODM as Provider Type 19, Specialty 190, with BCaBAs and RBTs delivering under supervision. The routing rule holds everywhere in Ohio: OhioRISE does not pay for ABA — ODM’s Mixed Services Protocol assigns ABA claims to the member’s MCO or fee-for-service even for OhioRISE-enrolled youth. [2][1]
- **Supervision** _(ask the plan)_: Follows the Ohio framework, which sets no fixed ratio: OAC 4783-6-02 requires the COBA to write a supervision plan into each client’s treatment plan, consult before plan initiation and modification, and observe directly on a periodic basis, with frequency left to documented clinical judgment and assessment, plan development and efficacy review non-delegable. No plan-specific numeric ratio was found for this MCO — note that other Ohio plans do publish one (Optum 1–2 hours per 10 direct hours weekly; Buckeye 97155 at 10–20% of direct hours). [2][1]
  - Ask the plan: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02. [2][1]
- **Place of service** _(ask the plan)_: No plan-specific place-of-service rule found. The confirmed Ohio boundary is the school one: the MCO is not responsible for payment of services provided through the Medicaid School Program under OAC Chapter 5160-35, 5160-35-04 and 5160-26-03. [2][1]
  - Ask the plan: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.

## What intake should collect for Humana Healthy Horizons in Ohio

- **Assessment PA first:** Unlike some plans, the assessment needs authorization — build it into the intake sequence.
- **ASD diagnosis (DSM-5-TR):** Comprehensive evaluation per the state baseline.
- **Authorization before service:** The retrospective-review penalty makes "start now, authorize later" a losing bet.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How Humana Healthy Horizons in Ohio ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00819
- **Payer ID (Change Healthcare / Optum):** 61103 — ODM FI MCE claims payer ID 61103 (companion guide, verified); a distinct Change Healthcare CPID was not separately confirmed.
- **Supports 270/271 eligibility:** Yes
- **Real-time eligibility:** Yes
- **Behavioral health administrator:** none — in-house Humana behavioral health
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes — administered on the OAC 5160-34 state framework; no distinct Humana ABA clinical policy | Required — every ABA code is on Humana's PA and notification list (eff. 1/1/2026), assessments included; services rendered without PA face retrospective medical-necessity review and financial penalties. Submit via Availity Essentials; OH provider line (877) 856-5707; in-house Humana behavioral UM. | 32 units/day (CMS MUE ceiling — the PAL is a PA list only, no per-code cap; state/CMS default) per day | — | — | — |
| 97152 | Yes — administered on the OAC 5160-34 state framework; no distinct Humana ABA clinical policy | Required — every ABA code is on Humana's PA and notification list (eff. 1/1/2026), assessments included; services rendered without PA face retrospective medical-necessity review and financial penalties. Submit via Availity Essentials; OH provider line (877) 856-5707; in-house Humana behavioral UM. | 16 units/day (CMS MUE ceiling — the PAL is a PA list only, no per-code cap; state/CMS default) per day | — | — | — |
| 97153 | Yes — administered on the OAC 5160-34 state framework; no distinct Humana ABA clinical policy | Required — every ABA code is on Humana's PA and notification list (eff. 1/1/2026), assessments included; services rendered without PA face retrospective medical-necessity review and financial penalties. Submit via Availity Essentials; OH provider line (877) 856-5707; in-house Humana behavioral UM. | 32 units/day (CMS MUE ceiling — the PAL is a PA list only, no per-code cap; state/CMS default) per day | — | — | — |
| 97154 | Yes — administered on the OAC 5160-34 state framework; no distinct Humana ABA clinical policy | Required — every ABA code is on Humana's PA and notification list (eff. 1/1/2026), assessments included; services rendered without PA face retrospective medical-necessity review and financial penalties. Submit via Availity Essentials; OH provider line (877) 856-5707; in-house Humana behavioral UM. | 18 units/day (CMS MUE ceiling — the PAL is a PA list only, no per-code cap; state/CMS default) per day | — | — | — |
| 97155 | Yes — administered on the OAC 5160-34 state framework; no distinct Humana ABA clinical policy | Required — every ABA code is on Humana's PA and notification list (eff. 1/1/2026), assessments included; services rendered without PA face retrospective medical-necessity review and financial penalties. Submit via Availity Essentials; OH provider line (877) 856-5707; in-house Humana behavioral UM. | 24 units/day (CMS MUE ceiling — the PAL is a PA list only, no per-code cap; state/CMS default) per day | — | — | — |
| 97156 | Yes — administered on the OAC 5160-34 state framework; no distinct Humana ABA clinical policy | Required — every ABA code is on Humana's PA and notification list (eff. 1/1/2026), assessments included; services rendered without PA face retrospective medical-necessity review and financial penalties. Submit via Availity Essentials; OH provider line (877) 856-5707; in-house Humana behavioral UM. | 16 units/day (CMS MUE ceiling — the PAL is a PA list only, no per-code cap; state/CMS default) per day | — | — | — |
| 97157 | Yes — administered on the OAC 5160-34 state framework; no distinct Humana ABA clinical policy | Required — every ABA code is on Humana's PA and notification list (eff. 1/1/2026), assessments included; services rendered without PA face retrospective medical-necessity review and financial penalties. Submit via Availity Essentials; OH provider line (877) 856-5707; in-house Humana behavioral UM. | 16 units/day (CMS MUE ceiling — the PAL is a PA list only, no per-code cap; state/CMS default) per day | — | — | — |
| 97158 | Yes — administered on the OAC 5160-34 state framework; no distinct Humana ABA clinical policy | Required — every ABA code is on Humana's PA and notification list (eff. 1/1/2026), assessments included; services rendered without PA face retrospective medical-necessity review and financial penalties. Submit via Availity Essentials; OH provider line (877) 856-5707; in-house Humana behavioral UM. | 16 units/day (CMS MUE ceiling — the PAL is a PA list only, no per-code cap; state/CMS default) per day | — | — | — |
| 0362T | Yes — administered on the OAC 5160-34 state framework; no distinct Humana ABA clinical policy | Required — every ABA code is on Humana's PA and notification list (eff. 1/1/2026), assessments included; services rendered without PA face retrospective medical-necessity review and financial penalties. Submit via Availity Essentials; OH provider line (877) 856-5707; in-house Humana behavioral UM. | 16 units/day (CMS MUE ceiling — the PAL is a PA list only, no per-code cap; state/CMS default) per day | — | — | — |
| 0373T | Yes — administered on the OAC 5160-34 state framework; no distinct Humana ABA clinical policy | Required — every ABA code is on Humana's PA and notification list (eff. 1/1/2026), assessments included; services rendered without PA face retrospective medical-necessity review and financial penalties. Submit via Availity Essentials; OH provider line (877) 856-5707; in-house Humana behavioral UM. | 32 units/day (CMS MUE ceiling — the PAL is a PA list only, no per-code cap; state/CMS default) per day | — | — | — |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** The PA list names 97151-97158, 0362T, 0373T explicitly under "Applied behavioral analysis (ABA) therapy" — so the assessment itself needs authorization before the first appointment (unlike Buckeye's in-network assessment waiver). Clinical criteria follow the state framework (DSM-5-TR, 6-month reviews). OhioRISE rule applies. Verify code-level POS/telehealth via Humana provider services.

### Contacts

- **Provider services phone:** (877) 856-5707
- **Portal:** [Availity Essentials](https://www.availity.com)

Questions to ask on a verification call:

- What POS codes are approved for ABA (home, school, clinic, telehealth)?
- Is telehealth allowed for any ABA code, and what modifier/POS number applies?
- Since every ABA code including assessments requires prior authorization here, what's the current turnaround time for a decision?
- Do you require a licensure-tier billing modifier?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://dam.assets.ohio.gov/image/upload/medicaid.ohio.gov/Providers/MITS/HIPAA%205010%20Implementation/CompanionGuide/OMES/FFS/Ohio270-271.pdf (accessed 2026-07-23)
- https://assets.humana.com/is/content/humana/OH%20MCD%20PAL%20Dpdf (accessed 2026-07-23)
- https://www.caqh.org/sites/default/files/CAQH%20CORE%20Eligibility%20Benefits%20(270_271)%20Data%20Content%20Rule%20vEB2.0.pdf (accessed 2026-07-23)
- https://codes.ohio.gov/ohio-administrative-code/rule-5160-34-02 (accessed 2026-07-23)

## Common questions

### Does Humana Healthy Horizons in Ohio cover ABA?

Yes — on the state clinical framework, with prior authorization required on every ABA code including assessments, submitted via Availity Essentials.

### What happens if we deliver ABA without a Humana authorization?

The service is subject to retrospective medical-necessity review and financial penalties — treat authorization-before-service as non-negotiable.

## Primary sources

1. [Humana Healthy Horizons OH — PA and notification list](https://assets.humana.com/is/content/humana/OH%20MCD%20PAL%20Dpdf)
2. [Ohio Administrative Code — rule 5160-34-02](https://codes.ohio.gov/ohio-administrative-code/rule-5160-34-02)
3. [OAC 5160-26-03.1 — MCO utilization management and authorization timeframes (eff. 1/1/2026)](https://codes.ohio.gov/ohio-administrative-code/rule-5160-26-03.1)
4. [Humana Healthy Horizons in Ohio — 2026 Provider Manual](https://assets.humana.com/is/content/humana/2025_OH_Provider_Manualpdf)
5. [OAC 5160-26-09.1 — MCO third party recovery and coordination of benefits](https://codes.ohio.gov/ohio-administrative-code/rule-5160-26-09.1)

Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.