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.
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]
Filing deadline: “Claims must be submitted within 365 days from the date of service or discharge date”; corrected claims within 365 days of the date of service or 180 days from the date Medicare or the other insurer paid. Payment: Humana pays 90% of clean claims within 21 calendar days of receipt, 99% within 60 and 100% within 90.[9][4]
Taxonomy: claims need “Billing and rendering taxonomy codes that match the ODM Master Provider List (MPL),” and billing and rendering addresses that match the MPL. Claim disputes (any provider disagreement with a claim decision): “within 12 months from the date of service or 60 calendar days after the payment, denial or partial denial of a timely claim submission, whichever is later.” Humana resolves a claim dispute within 15 business days.[9][4]
EVV does not apply to ABA in Ohio. OAC 5160-32-01 lists the services subject to Ohio’s EVV program — named waiver services in the home care, MyCare, PASSPORT and developmental-disability waivers, plus state-plan home health, private duty nursing and RN assessment and consultation — and makes managed care entities responsible for applying it; ABA is not on the list, and services delivered by telehealth are exempt. Humana’s own EVV list names home health, nursing, therapy and personal-care codes (G0156, G0299, G0300, T1000–T1003, S5125, T1019, T2025, G0151–G0153), not ABA codes.[9][4]
The questions that decide whether a family can start with Humana Healthy Horizons in Ohio, and what they have to bring. Each maps onto something intake should ask on the first call.
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]
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]
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.[10][9]
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).[9][11]
Ask the plan: Humana Healthy Horizons in Ohio Provider Services: whether a Humana ABA authorization is required when a commercial plan pays first.
Follows the Ohio Medicaid framework, which publishes no verifiable age bound for ABA; under-21 members carry EPSDT protections through the MCO. codes.ohio.gov now returns “No Ohio Administrative Code rule number corresponds to ‘5160-34’” (re-confirmed 10/1/2026) rather than refusing the connection, and the chapter remains absent from the Title 5160 index, so no in-force rule text exists to read — confirm with Rules@Medicaid.Ohio.gov or JCARR. Per ODM’s 7/30/2026 provider stakeholder presentation, the rewrite was paused in 2025 for reevaluation (budget pressure, national ABA-spend scrutiny, other-state audit findings) and the draft (ERF188422B) still carries a “DRAFT — NOT FOR FILING” header and no JCARR filing, so draft content does not govern.[2][1]
Blocked on: 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.
No plan-specific recency rule found — the Ohio Medicaid framework requires a documented comprehensive diagnostic evaluation demonstrating DSM-5-TR criteria but publishes no verifiable window. Note that two Ohio MCOs do set one (CareSource: a symptom letter where the evaluation is over 24 months old; Buckeye: a CDE within 5 years), so do not assume this plan is silent — confirm in its portal. codes.ohio.gov now returns “No Ohio Administrative Code rule number corresponds to ‘5160-34’” (re-confirmed 10/1/2026) rather than refusing the connection, and the chapter remains absent from the Title 5160 index, so no in-force rule text exists to read — confirm with Rules@Medicaid.Ohio.gov or JCARR. Per ODM’s 7/30/2026 provider stakeholder presentation, the rewrite was paused in 2025 for reevaluation (budget pressure, national ABA-spend scrutiny, other-state audit findings) and the draft (ERF188422B) still carries a “DRAFT — NOT FOR FILING” header and no JCARR filing, so draft content does not govern.[2][1]
Blocked on: 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.
No plan-specific instrument list found, and the state framework names none. Other Ohio MCOs do publish lists (CareSource: ADOS, ADI-R or CARS-2; Optum for UHC Community Plan: one validated screener plus one formal tool), so confirm in this plan’s portal rather than assuming. codes.ohio.gov now returns “No Ohio Administrative Code rule number corresponds to ‘5160-34’” (re-confirmed 10/1/2026) rather than refusing the connection, and the chapter remains absent from the Title 5160 index, so no in-force rule text exists to read — confirm with Rules@Medicaid.Ohio.gov or JCARR. Per ODM’s 7/30/2026 provider stakeholder presentation, the rewrite was paused in 2025 for reevaluation (budget pressure, national ABA-spend scrutiny, other-state audit findings) and the draft (ERF188422B) still carries a “DRAFT — NOT FOR FILING” header and no JCARR filing, so draft content does not govern.[2][1]
Blocked on: 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.
No plan-specific ABA telehealth rule found. ODM’s 2026 Telehealth Billing Guidelines (fee-for-service, under OAC 5160-1-18) list no ABA code — 97151–97158, 0362T, 0373T — as telehealth-eligible and do not name behavior analysts among eligible telehealth practitioners, while saying the MCOs “cover the same telehealth services as in fee-for-service but may have different billing requirements.” So remote assessment (97151) or supervision (97155) is not established in any document we could read for this plan; ask before scheduling it.[2][1][3]
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.
Coverage decides whether Humana Healthy Horizons in Ohio pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Humana’s 2026 Ohio provider manual publishes no ABA per-day unit table. The state rule it works under: ODM’s managed care provider agreement requires every MCO to “implement claims edits (e.g., … National Correct Coding Initiative [NCCI]) at the direction of ODM” (App. K §5c), and OAC 5160-1-19(B) has claims submitted pursuant to NCCI. The CMS Medicaid NCCI practitioner MUE table active 10/1–12/31/2026 sets 97151 at 32 units, 97152 at 16, 97153 at 32, 97154 at 18, 97155 at 24, 97156 at 16, 97157 at 16, 97158 at 16, 0362T at 16 and 0373T at 32 units per date of service. Those are claim edits; the weekly ceiling is whatever the prior authorization approves.[7][5][6]
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]
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.
Not resolved. No state-level rule on billing 97153 and 97155 for the same clock time could be verified, and this plan publishes none. codes.ohio.gov now returns “No Ohio Administrative Code rule number corresponds to ‘5160-34’” (re-confirmed 10/1/2026) rather than refusing the connection, and the chapter remains absent from the Title 5160 index, so no in-force rule text exists to read — confirm with Rules@Medicaid.Ohio.gov or JCARR. Per ODM’s 7/30/2026 provider stakeholder presentation, the rewrite was paused in 2025 for reevaluation (budget pressure, national ABA-spend scrutiny, other-state audit findings) and the draft (ERF188422B) still carries a “DRAFT — NOT FOR FILING” header and no JCARR filing, so draft content does not govern.[2][1]
Blocked on: 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.
No plan-specific session-note signature standard found, and none could be verified at state level. codes.ohio.gov now returns “No Ohio Administrative Code rule number corresponds to ‘5160-34’” (re-confirmed 10/1/2026) rather than refusing the connection, and the chapter remains absent from the Title 5160 index, so no in-force rule text exists to read — confirm with Rules@Medicaid.Ohio.gov or JCARR. Per ODM’s 7/30/2026 provider stakeholder presentation, the rewrite was paused in 2025 for reevaluation (budget pressure, national ABA-spend scrutiny, other-state audit findings) and the draft (ERF188422B) still carries a “DRAFT — NOT FOR FILING” header and no JCARR filing, so draft content does not govern.[2][1]
Blocked on: 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.
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.
Yes — on the state clinical framework, with prior authorization required on every ABA code including assessments, submitted via Availity Essentials.
The service is subject to retrospective medical-necessity review and financial penalties — treat authorization-before-service as non-negotiable.
Yes. Billing and rendering taxonomy codes must match the ODM Master Provider List (Humana Ohio provider manual, 2026). Claims are due within 365 days of the date of service.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 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.
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