Humana Inc. · NYSE:HUM
Humana — Investor Presentation (2025)
76 slides from Humana's investor presentation, 2025
Slide 1: 2025 Provider Orientation and Training
2025 Provider Orientation and Training Information for Oklahoma Medicaid healthcare providers and administrators Humana Healthy Horizons in Oklahoma is a Medicaid product of Humana Wisconsin Health Organization Insurance Corporation. 569301OK1024 OKHM86HEN
Slide 2: Humana has more than 30 years of experience serving Oklahomans
Humana has more than 30 years of experience serving Oklahomans Humana has proudly served Oklahomans since 1987 and is the only Medicare Advantage (MA) plan working statewide. We currently serve more than 278,000 Oklahomans in our Medicare plans, Dual Eligible Special Needs Plans (D-SNPs), TRICARE an
Slide 3: SoonerSelect program
SoonerSelect program SoonerSelect is a new health delivery model in Oklahoma that began April 1, 2024. What is SoonerSelect? SoonerSelect is a healthcare delivery model used to coordinate health and dental care and improve quality of care. SoonerSelect provides Medicaid health benefits through contr
Slide 4: Member eligibility and enrollment
Member eligibility and enrollment Determination Oklahoma Health Care Authority (OHCA) determines a member’s eligibility and will provide eligibility information to Humana Healthy Horizons. Newborn coverage You can verify Newborn coverage starts on the date of birth when the newborn’s mother is a mem
Slide 5: PCP assignment and changes
PCP assignment and changes • Members choose or are assigned to a PCP on enrollment with Humana Healthy Horizons. PCPs help coordinate healthcare for members and provide additional health options to members for self-care or care from community partners. Members select a PCP from the Humana Healthy Ho
Slide 6: Sample ID card
Sample ID card Humana Healthy Horizons. in Oklahoma A Medicaid product of Humana WI Heelth Org. Ins. Corp MEMBER NAME MEMBER ID: HXXXXXXXX Medicaid [D#: XXXXXXXX Group #: XXXXX Date of Birth: XX/XX/XX RxBIN: 610649 RxPCN: 03191505 SoonerSelect } In cose cf emergency, call 914 or go to the closest em
Slide 7: Member rewards
Member rewards Members have an opportunity to earn rewards for taking healthy actions through Go365® for Humana Healthy Horizons. Providers can help members obtain rewards by submitting claims on behalf of a member, within 6 months from the date of service but no later than March 15, 2026. This allo
Slide 8: Concierge provider services team
Humana Healthy Horizons in Oklahoma deploys a concierge provider services team enabling a transparent and seamless provider experience Our provider partnerships allow us to deliver high-quality managed care medical and behavioral health services to eligible Oklahoma residents with SoonerSelect cover
Slide 9: Provider support team
Provider support team Our provider support team is led by our Director of Provider Services Provider Relations Provider Engagement Contact information Representatives Representatives • Are local, high-touch representatives • Work with providers to Provider Services Center regionally assigned by prov
Slide 10: Overview of provider website
Overview of provider website Visit Humana.com/HealthyOK for additional resources. Provider Quick Training calendar Provider manual resource guide reference guides Provider Relations Representative Transportation Pharmacy Dental vendors contacts and territory map Relias (tobacco Vision cessation and
Slide 11: Availity Essentials
Availity Essentials Availity Essentials is our provider portal. Through Availity Essentials, you have access to: • Patient management • Claims management and status • Provider engagement • Authorization and referral management • Electronic funds transfer (EFT) and electronic remittance advice (ERA)
Slide 12: Claim processing
Claim processing Humana Healthy Horizons will process accurate and complete provider claims in accordance with its normal claims processing procedures, including claims processing edits, claims payment policies and applicable state and/or federal laws, rules and regulations. Humana Healthy Horizons
Slide 13: Submitting electronic and paper claims
Submitting electronic and paper claims Here are some commonly used clearinghouses: Paper claims can be submitted on: • Availity Essentials • CMS-1500, formerly HCFA 1500 form-AMA • Change Healthcare universal claim form also known as the • TriZetto National Standard Format (NSF) • SSI Group • CMS-14
Slide 14: Encounter submissions
Encounter submissions Humana Healthy Horizons submits Encounter data is submitted in 100% of its encounter data accordance with OHCA accuracy including capitated arrangements standards of 95% for submitted to OHCA. and accepted encounters. Humana Healthy Horizons uses the electronic data interchange
Slide 15: Encounter submission and remediation
Encounter submission and remediation • Humana Healthy Horizons will submit 100% of its encounter data including, capitated arrangements, to OHCA for services rendered to a member that resulted in a paid, denied, corrected, voided or zero paid claim. We also will submit encounter data in accordance w
Slide 16: Timely filing requirements
Timely filing requirements Initial claims must be submitted within 6 months from the date of service or discharge. Corrected claims must be submitted within 12 months from the date of service or discharge. Claims will not be paid if they have incomplete, incorrect or unclear information. | 16
Slide 17: Overpayments
Overpayments Healthcare providers must report to Humana Healthy Horizons any service claim overpayments for medical services rendered to Medicaid managed-care plan members, in accordance with the OHCA contract. Regardless of agreement specifics, the provider or subcontractor agrees to submit such cl
Slide 18: Balance billing
Balance billing • State requirements and federal regulations prohibit you from billing Humana members for medically necessary covered services except under very limited circumstances. Providers who knowingly and willfully bill a member for a Medicaid-covered service are guilty of a felony and on con
Slide 19: Prior authorizations
Prior authorizations • Prior authorization (PA) is the process through which healthcare providers obtains approval from the plan as Prior to whether an item, drug or service will be covered. authorization (PA) • Visit Availity Essentials and complete an authorization request. • Call 855-223-9868 and
Slide 20: Utilization Management
Utilization Management Utilization Management (UM) includes PA, concurrent reviews, discharge planning and other activities such as monitoring initial and ongoing inpatient and outpatient admissions. UM also reviews covered services based on medical necessity, appropriateness of care and service, an
Slide 21: Second opinions
Second opinions Members and providers may request a second opinion for surgery or medical services at no cost. The following is criteria that should be used when selecting a provider for a second opinion. The provider must participate in the Humana Healthy Horizons network. If an in-network provider
Slide 22: Referral process
Referral process Humana Healthy Horizons has policies and procedures in place to guide PCP referrals to ensure timely, appropriate care for a member’s condition. Humana Healthy Horizons does not require a referral to in-network specialists. • Behavioral health services, including SUD treatment • Vis
Slide 23: Female members
Female members • Humana Healthy Horizons covers services when the PCP is not a woman’s health specialist. The plan will provide the member with direct access to a women’s health specialist within the provider network for covered routine and preventive women’s healthcare services. • Woman’s health se
Slide 24: Family planning services
Family planning services Members, including adolescents, may receive family planning services and related supplies from appropriate Medicaid family planning providers regardless of network status. Referrals and PAs are not required. Services include: • Comprehensive medical history and physical exam
Slide 25: Transition of care
Transition of care Humana Healthy Horizons will allow members to continue an existing During this period, PAs will Humana Healthy Horizons relationship with a not be denied if the honors previously approved nonparticipating provider provider is not in network, authorizations for 90 days during this
Slide 26: Credentialing and recredentialing
Credentialing and recredentialing Humana Healthy Horizons will transition to a Credentials Verification Organization (CVO) for credentialing and recredentialing by July 1, 2025, as required by OHCA. Until the CVO is implemented, Humana Healthy Horizons will only consider OHCA’s provider enrollment s
Slide 27: Types of providers within scope of credentialing
Types of providers within the scope of credentialing, recredentialing or assessment Physical health providers Licensed behavioral health providers • Nurse practitioners • Physician assistants • Psychiatrists: • Licensed clinical addiction • Medical doctors (M.D.) • Other medical practitioners ̶ M.D.
Slide 28: Organizations within scope of credentialing and recredentialing
Organizations within the scope of credentialing and recredentialing Physical health Behavioral health • Ambulatory surgery centers • Laboratories • Organizations providing behavioral health or • Dialysis centers/end stage renal • Outpatient physical therapy and substance use services in the followin
Slide 29: Contractual demographic changes
Contractual demographic changes We should be notified 30 days prior of changes such as: • Change to the Tax Identification Number (TIN) • Providers added to the group You can notify us by: • Providers leaving the group Phone • Service address updates • 855-223-9868 (e.g., new location, phone or fax)
Slide 30: Provider rights
Provider rights Healthcare providers who contract with Humana Healthy Horizons to furnish services to the member shall be assured of the following rights: • To advise and advocate on behalf of members, including the right to file a grievance or appeal on behalf of a member as the member’s authorized
Slide 31: Provider responsibilities
Provider responsibilities To comply with the requirements of accrediting and regulatory agencies, Humana Healthy Horizons has adopted certain responsibilities for participating providers. You have responsibilities to: • Provide all covered services that are within the normal • Accommodate interprete
Slide 32: Provider responsibilities (cont'd)
Provider responsibilities (cont’d) To comply with the requirements of accrediting and regulatory agencies, Humana Healthy Horizons has adopted certain responsibilities for participating providers. You have responsibilities to: • Make all member medical records or other service • Sign a participation
Slide 33: Provider responsibilities (cont'd)
Provider responsibilities (cont’d) To comply with the requirements of accrediting and regulatory agencies, Humana Healthy Horizons has adopted certain responsibilities for participating providers. You have responsibilities to: • Participate and cooperate in internal and external quality management o
Slide 34: Primary care provider (PCP) responsibilities
Primary care provider (PCP) responsibilities In addition to the provider responsibilities in the previous section of this training, PCPs also have the following responsibilities: • Delivering primary care services and follow-up care • Ensuring coordination and continuity of care with • Utilizing and
Slide 35: Behavioral health provider responsibilities
Behavioral health provider responsibilities In addition to the provider responsibilities in the previous sections of this training, behavioral health providers also have the following responsibilities: • Scheduling the member receiving inpatient psychiatric services for outpatient follow-up care pri
Slide 36: Conditions of participation
Conditions of participation Providers are required to meet all state and federal participation requirements, including, but not limited to, background screening compliance. Conditions of your participation are continuously monitored. Required status notifications • Being named in a medical malpracti
Slide 37: Provider complaint system
Provider complaint system If you are not satisfied with Humana Healthy Horizons’ policies and procedures or a decision made by Humana Healthy Horizons that does not impact the provision of services to members, you can file a provider complaint. Humana Healthy Horizons’ provider complaint system cons
Slide 38: Provider complaint system: reconsiderations
Provider complaint system: reconsiderations Reconsideration: A reconsideration request may be filed using any of these methods: If your reconsideration request is In person: Please reach out to your Provider Relations Representative regarding a denied claim, you have 6 For claims: months from receiv
Slide 39: Provider complaint system: formal appeals
Provider complaint system: formal appeals Formal appeal: Process for filing a formal claim appeal: Dissatisfied with the determination of the • A provider’s request for reconsideration is required before requesting reconsideration request related to policies and a formal appeal. procedures, Provider
Slide 40: Provider complaint system
Provider complaint system Administrative appeal In the event you have completed the formal appeal process and remain dissatisfied with Humana’s determination, you have the option to request an administrative appeal within 30 calendar days of the date of the appeal determination. You have the right t
Slide 41: Accessibility and availability standards
Accessibility and availability standards and methods of identifying compliance Providers must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid fee-for-service if the provider serves only Medicaid managed care members. Parti
Slide 42: Appointment time standards
Appointment time standards Provider type Appointment time standards Adult PCP • Not to exceed 30 days from date of the Humana Healthy Horizons member’s request for Pediatric PCP routine appointment • Within 72 hours for nonurgent sick visits • Within 24 hours for urgent care • Each PCP allowing for
Slide 43: Member rights and responsibilities
Member rights and responsibilities • Humana Healthy Horizons contracted providers have a responsibility to respect our member’s rights. • Members are informed of their rights and responsibilities in the member handbook. • Detailed information on provider and member rights and responsibilities can be
Slide 44: Grievances and appeals
Grievances and appeals Members or their authorized Member grievances and appeals representatives can file a contact information Grievances grievance at any time, orally or in writing, if they are dissatisfied with Humana Healthy Horizons Mail or any aspect of their care. Humana Grievance and Appeal
Slide 45: Grievances and appeals continued
Grievances and appeals continued Grievances • We will resolve the member’s grievance as quickly as the member’s health condition requires. • Grievances concerning a member’s request for disenrollment will be resolved within 10 days from the date of receipt. • Grievances regarding all other matters w
Slide 46: Continuation of benefits
Continuation of benefits While the state fair hearing or appeal is pending, we will continue paying for the member’s benefits if all the following conditions are met: • The appeal involves the termination, suspension or reduction of previously authorized services • The services were ordered by an au
Slide 47: Medicaid state fair hearing
Medicaid state fair hearing If the appeal decision is not fully in the fully member’s in the favor, the member If the appeal decision is not member’s favor, or the member’s authorized representative can appeal to Oklahomacan Health Care the member or the member’s authorized representative appeal Aut
Slide 48: Critical incident reporting
Critical incident reporting When a member is in the care of a behavioral health inpatient, residential or crisis stabilization unit, critical incidents can include, but are not limited to, the following, in accordance with OAC 317:30-5-95.39: • Suicide death • Accidental injury with significant medi
Slide 49: Critical incident reporting timeline
Critical incident reporting timeline • Psychiatric Residential Treatment Facility (PTRF) providers are required to report adverse or critical incidents to Humana Healthy Horizons, the OHCA Behavioral Health Unit and Oklahoma Department of Human Services (OKDHS) by phone no later than 5 p.m. on the b
Slide 50: Reporting potential cases of abuse, neglect and exploitation of members
Reporting potential cases of abuse, neglect and exploitation of members Abuse, neglect or exploitation must be reported in accordance with state law. • Any person suspecting child abuse or neglect shall immediately report it to the Oklahoma Department of Human Services (OKDHS) hotline, at 800‐522‐35
Slide 51: Advance directives
Advance directives • All member records shall contain documentation that the member was provided with written information concerning the member’s rights regarding advance Providers have the responsibility to discuss directives (written instructions for living will or power of attorney), including wh
Slide 52: Behavioral health
Behavioral health As a Humana Healthy Horizons healthcare provider, you can take advantage of Relias—a web-based continuing education library. Relias offers more than 300 modules to choose from and over 575 continuing education credits, in addition to behavioral health training. Relias’ training mod
Slide 53: How to access the Relias library
How to access the Relias library • Visit the Relias website or sign in to your Availity Essentials account. • Select Humana under the Payer Spaces tab. • Select the Resources tab. • Select Relias Training. For more information, please contact your Provider Relations Representative. | 53
Slide 54: Behavioral health referral process
Behavioral health referral process PCPs could encounter a member that also needs behavioral health services during their visit. Should a member be identified as such: • The PCP may refer the member to Humana.com/FindADoctor to utilize the provider directory. Our provider directory will allow members
Slide 55: Behavioral health provider coordination
Behavioral health provider coordination Humana’s providers are required to coordinate care for members who experience behavioral health conditions that require ongoing care. PCPs are required to: • Provide basic behavioral health services to members to include: ̶ Screening for mental health and subs
Slide 56: Behavioral health provider coordination continued
Behavioral health provider coordination continued Behavioral health providers are required to: • Notify the PCP when a member initiates behavioral health services with the provider. • Obtain the signed release of information for sharing personal health information in compliance with 42CFR Part II re
Slide 57: Care management
Care management Humana Healthy Horizons coordinates care and population health services for our members. The care plan will be person-centered and holistic with services that address the member’s physical care, behavioral health and community and social support needs. Care management supports member
Slide 58: Care management participation and referrals
Care management participation and referrals Humana Healthy Horizons encourages providers to participate in the development of the patients’ comprehensive care plan. Member care plans and health risk assessments are viewable, with member consent, on Availity Essentials. Providers can contact Humana H
Slide 59: Care management
Care management Humana Healthy Horizons uses a holistic and fully integrated health management program using a multidisciplinary team to ensure the best and most comprehensive care for our members. This approach supports members by: Care management programs include: • Reducing admission and readmiss
Slide 60: Oklahoma care management operating model roles
Oklahoma care management operating model roles Care manager − Maternity care Transition coordinator Tribal liaison (physical and behavioral health) management • Collaborates with the UM team • Tribal Government adult and pediatrics • Supports pregnant members regarding discharge planning for Liaison
Slide 61: Oklahoma care management operating model roles (cont'd)
Oklahoma care management operating model roles (cont’d) SDOH coordinator Housing specialist Care manager Community support assistant • Support members • Supports members with SDOH health worker specific to housing telephonically with short term • Nonclinical support for • Supports in the field locat
Slide 62: Risk stratification model
Risk stratification model Member movement based on need and clinical judgement Medium-risk Low-risk members Wellness and Complex care High-risk members members These members typically prevention management Members require the most These members typically demonstrate conditions Humana Healthy Horizon
Slide 63: Care management team capabilities
Care management team capabilities Care management Care management supporting roles (primarily telephonic) • SDOH–telephonic Care coordinators, case managers, • Transition – telephonic care managers and care coaches are • CHWs–face-to-face often used interchangeably. • Case manager support assistants
Slide 64: Early and Periodic Screening, Diagnostic and Treatment
Early and Periodic Screening, Diagnostic and Treatment • Early and Periodic screening, Diagnostic and Treatment (EPSDT) is a federally mandated program developed for Medicaid recipients from birth through the end of the month of their 21st birthday. • All Humana Healthy Horizons members in this age
Slide 65: Fraud, waste and abuse definitions
Fraud, waste and abuse definitions Fraud • Intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to themself or some other person. It includes any act that constitutes fraud under applicable federal or state law. W
Slide 66: Cultural and linguistic competency
Cultural and linguistic competency Cultural humility and competency in Participating providers are expected healthcare acknowledge and to provide services in a culturally Services should be delivered in a recognize the distinctions and unique sensitive and competent manner culturally aware manner fo
Slide 67: Cultural and linguistic competency (cont'd)
Cultural and linguistic competency (cont’d) How to interact with patients across cultures and underserved communities Keep an open mind. Ask patients about their concerns Remember that each regarding their health condition, (e.g., Be aware of your own patient has a unique "What do you think caused t
Slide 68: American Indian/Alaska Native — cultural competency
American Indian/Alaska Native — cultural competency Humana Healthy Horizons has supports in place to assist Indian Health Care Providers (IHCPs) navigate Medicaid managed care. • IHCPs can contact their assigned Provider Relations Representative with questions about Humana or Medicaid; questions abo
Slide 69: American Indians/Alaska Natives cultural competency
American Indians/Alaska Natives cultural competency In comparison to people who are AIs and ANs report experiencing Living in rural/reservation white, people who are AI/AN serious psychological distress areas can limit access to primary often face limited opportunities 2.5 times more frequently than
Slide 70: Health equity
Health equity Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health. Differences in access, treatment and outcomes between individuals are often referred to as inequities or disparities. • Achieving this requires valuing everyone equally
Slide 71: Quality assessment and performance improvement program
Humana’s quality assessment and performance improvement program Population health Administrative Clinical care Preventive care management functions Our quality assessment and performance QAPI program activities include: improvement (QAPI) program works to: • Clinical indicators or outcome monitoring
Slide 72: Humana's QAPI program
Humana’s QAPI program Clinical practice guidelines: Medical record documentation reviews (MRDRs): These protocols incorporate evidence-based Humana Healthy Horizon’s medical records medical and behavioral health guidelines from standards are in accordance with OHCA recognized sources such as profess
Slide 73: Humana's QAPI program continued
Humana’s QAPI program continued HEDIS measures: Member satisfaction: HEDIS is a tool used by more than 90% of America’s health plans to measure Humana conducts an annual member satisfaction performance on important dimensions of care and service. survey of a representative sample of members. Humana
Slide 74: Provider participation in QAPI program
Provider participation in QAPI program • Providers also must allow Humana to use provider performance data. • Our QAPI program effectiveness is evaluated annually. • Information regarding the QAPI program is available It is a contractual requirement upon request. for providers to comply with To rece
Slide 75: Required training and annual compliance
Required training and annual compliance Visit Humana.com/HealthyOK for direct links to this training and information on how to complete the annual training and required attestation. Fraud, waste and abuse Prevention, detection and report of abuse, neglect and exploitation Cultural humility, health e
Slide 76: SoonerSelect
Humana Healthy Horizons« SoonerSelect » in Oklahoma